Certified Risk Adjustment Coder (CRC)

Which diagnoses can be coded from a medical record that states a member has the condition, but does not contain supporting documentation?

1. COPD, Croup

2. A-Fib, GERD, Parkinson's disease, MS

3. Croup, Parkinson's disease, MS

4. COPD, A-Fib, Parkinson's disease, MS

The correct answer is: COPD, A-Fib, Parkinson's disease, MS

The correct response is based on the principles of coding and the guidelines set forth for risk adjustment coding. In risk adjustment coding, particularly for conditions such as COPD, A-Fib, Parkinson's disease, and MS, specific documentation is vital to support the diagnosis. When a medical record states that a patient has a condition, but lacks additional supporting documentation (for example, diagnostic tests, physician notes, or treatment details), it may limit the ability to code certain diagnoses. However, for chronic conditions that are frequently established through long-term management or ongoing treatment—like COPD, A-Fib, Parkinson's disease, and MS—having a clear indication of the diagnosis provides a basis for coding, even if additional documentation isn't explicitly available at that moment. This reinforces the value of these diagnoses in risk adjustment models, as they typically come with established treatment plans. Additionally, the presence of such conditions in a patient's ongoing care plan usually implies that they have been diagnosed and documented in the past, allowing coders to rely on the stated diagnosis in this context. Recognizing these factors clarifies why the combination of COPD, A-Fib, Parkinson's disease, and MS can be coded when those conditions are recorded in the medical record. In contrast, other combinations may