Certified Risk Adjustment Coder (CRC)

Which element of the medical record is never allowed to be used to capture current diagnosis codes?

1. Exam

2. Past medical history

3. Radiology report

4. Assessment

The correct answer is: Exam

In the context of coding for current diagnoses, the assessments made during the examination of the patient are crucial, as they provide real-time insights into the patient's condition. However, the past medical history serves a different purpose. It documents previous medical conditions that may affect the patient's current treatment but not necessarily relate to the patient's current diagnoses. The past medical history can inform healthcare providers about pre-existing conditions, which can influence the treatment plan, yet it does not reflect the patient's present state. Current diagnosis codes specifically require documentation that indicates the ongoing or active status of a condition, which the past medical history does not provide. While exam findings and assessments contribute to coding current diagnoses, past medical history purely outlines previously diagnosed conditions. Consequently, it is recognized that this element of the medical record should not be utilized for capturing current diagnosis codes, as it does not provide evidence of a present diagnosis that warrants such coding.