Certified Risk Adjustment Coder (CRC)

What can potentially occur if a coder does not carefully review patient histories in an EHR?

1. The coder may overlook current conditions.

2. The coder may create duplicate entries.

3. The coder may apply incorrect codes.

4. The coder may have to consult a physician for clarification.

The correct answer is: The coder may overlook current conditions.

Reviewing patient histories in an Electronic Health Record (EHR) is crucial for accurate coding. If a coder does not carefully conduct this review, it can lead to the oversight of current conditions that are essential for proper documentation and coding. Current conditions must be accurately captured to ensure comprehensive risk adjustment and appropriate reimbursement. By missing these details, the coder might fail to report all relevant diagnoses, potentially leading to inadequate risk adjustment and financial inaccuracies for healthcare providers. While overlooking current conditions is a significant consequence, coders may also face other issues, such as inaccurately coding existing diagnoses or missing new developments in a patient's health status. This thoroughness in reviewing patient histories helps maintain the integrity of medical coding and supports optimal patient care.