Certified Risk Adjustment Coder (CRC)

Which of the following statements about coding diagnoses for HCC coding is TRUE?

1. Codes can only be assigned from documentation in the assessment and plan.

2. Codes can only be assigned from documentation in the exam, assessment, and plan.

3. Codes can only be assigned from documentation in the PMH and ROS.

4. Codes can be assigned from documentation within the entire note.

The correct answer is: Codes can be assigned from documentation within the entire note.

The correct statement about coding diagnoses for Hierarchical Condition Category (HCC) coding being that codes can be assigned from documentation within the entire note is accurate for several reasons. HCC coding principles emphasize the importance of utilizing all relevant parts of the patient's medical documentation to accurately capture the patient's health status. This includes examination findings, history, assessments, plans, and any other relevant notes made by healthcare providers throughout the encounter. By considering the entire medical note, coders ensure a comprehensive understanding of the patient's condition, which in turn supports appropriate coding that reflects the patient's diagnoses and risk factors. This holistic approach helps to ensure that the coding is reflective of the patient's complexities, which is essential for risk adjustment. Properly capturing all relevant diagnoses from various sections of the documentation leads to correct reimbursement and meaningful analytics regarding patient health outcomes. In summary, the ability to extract diagnostic codes from the entire note allows coders to provide a more complete representation of the patient's clinical picture, aligning with HCC coding standards.