Certified Risk Adjustment Coder (CRC)

Which of the following statements is true concerning diagnoses providers should document to support each E/M visit?

1. Document only for the diagnosis the provider treated for that day.

2. Document for all diagnoses for all conditions that the patient has ever had.

3. Document only for the main reason the patient was seen today.

4. Document all diagnoses that are a part of the medical decision making (MDM) for each visit.

The correct answer is: Document all diagnoses that are a part of the medical decision making (MDM) for each visit.

The correct statement is that providers should document all diagnoses that are a part of the medical decision making (MDM) for each visit. This ensures that the medical record accurately reflects the complexity of the patient’s condition, the care provided, and the decision-making process during the encounter. Comprehensive documentation is vital for several reasons. First, it provides a clear rationale for the services provided, which is essential for compliance and possible audits. It helps ensure that all relevant conditions are taken into account when planning the patient's treatment, which can affect the decision-making process significantly. Moreover, thorough documentation supports appropriate coding and billing, ensuring that the services provided align with the code selected and the diagnoses reported. Addressing the incorrect options, focusing solely on the diagnosis treated that day does not capture the full scope of the patient’s health status or the documentation needed to support a well-rounded evaluation. Documenting every diagnosis a patient has ever had would be overly burdensome and could lead to irrelevant information being included in the medical record. Lastly, only documenting the main reason for the visit neglects the complexity of the patient's health issues and fails to adequately represent the care provided and the MDM involved. Thus, the comprehensive approach of including all relevant diagnoses within the framework of MDM