Certified Risk Adjustment Coder (CRC)

Which of the following would prevent a chart from being coded for Medicare risk adjustment?

1. Patient's DOB is not documented on the medical record

2. The patient presented for an acute condition

3. Medical record does not include the credentials of the treating provider

4. Date of service is past 90 days

The correct answer is: Medical record does not include the credentials of the treating provider

The correct answer highlights an important aspect of compliance and validation in risk adjustment coding. Medicare requires that medical records include the necessary credentials of the treating provider to verify the appropriate level of care and expertise provided to the patient. If the credentials are missing, it may raise questions about the legitimacy of the care documented in the record, potentially leading to challenges during audits or eligibility assessments for risk adjustment. Having the treating provider's credentials ensures that the care provided is compliant with Medicare’s regulations and guidelines. Moreover, it establishes the clinical authority behind the diagnoses and treatment outlined in the chart, which is essential for accurate risk adjustment coding. This validation supports the claim that the patient received care that is relevant to their health status and needs. In contrast, aspects like the patient's date of birth not being documented or the date of service being past 90 days do not directly negate the possibility of coding but rather present challenges in coding accuracy or compliance. Similarly, acute conditions are typically eligible for coding, depending on the context and whether they contribute to the risk adjustment model.