Certified Risk Adjustment Coder (CRC)

What type of documentation can support diagnoses reported under risk adjustment models?

1. Inpatient admission note

2. CT scan results

3. CBC lab test

4. Comprehensive problem list

The correct answer is: Inpatient admission note

The correct answer is an inpatient admission note. This type of documentation is crucial for risk adjustment models because it typically provides comprehensive and detailed information about a patient's current health status at the time of admission. Admission notes often include the patient's history, physical examination findings, and any diagnoses that the healthcare provider has made based on their evaluation. This thorough documentation is essential as it helps ensure that all pertinent diagnoses are captured accurately, which is critical for risk adjustment purposes. While CT scan results and CBC lab tests can support diagnoses, they generally do not convey the same level of comprehensive clinical context as an admission note. A CT scan may show a specific condition, but it doesn't communicate the patient's overall health or the physician's reasoning for a diagnosis. Similarly, a CBC test provides valuable blood information but lacks the overall clinical assessment and context that are essential for risk adjustment coding. A comprehensive problem list is important in providing an overview of the patient’s health but does not carry the same weight in a risk adjustment scenario as the detailed narrative found in an inpatient admission note. Thus, the admission note stands out for its detailed narrative and context, making it the strongest option for supporting diagnoses under risk adjustment models.