Certified Risk Adjustment Coder (CRC)

What condition is generally documented in the patient’s chart as “history of”?

1. Currently managed hypertension

2. Recently treated diabetes

3. Colon cancer treatment years ago

4. Ongoing asthma symptoms

The correct answer is: Colon cancer treatment years ago

The condition that is documented in the patient’s chart as “history of” refers to a past medical condition that has been resolved or treated and is no longer current, but still needs to be recognized for risk adjustment coding and comprehensive patient history. Documenting a condition as "history of" is important for acknowledging the patient's previous medical issues that may still affect their health risks, even if they are not actively being treated. In the case of colon cancer treatment years ago, it signifies that the patient has a past medical history of this condition but is no longer undergoing active treatment for it, allowing it to be classified as a historical condition. This documentation helps healthcare providers understand the patient's background, which is crucial for future medical care and coding accurately for risk adjustment purposes. Other conditions listed, such as currently managed hypertension, recently treated diabetes, and ongoing asthma symptoms are actively being managed or treated. They do not fall under the classification of “history of” since they are current issues that require ongoing monitoring and intervention.