Certified Risk Adjustment Coder (CRC)

Which scenario indicates a current diagnosis for a patient?

1. Patient has a history of DVTs.

2. Patient presents for a follow up for resolved pneumonia.

3. Patient has a history of COPD which is stable with current medication regimen.

4. Patient appears to have an early onset of dementia.

The correct answer is: Patient has a history of COPD which is stable with current medication regimen.

The scenario that indicates a current diagnosis for a patient is grounded in the details concerning the patient's ongoing health condition. The choice highlighting a patient with a history of COPD, who is currently stable on a medication regimen, suggests that while the disease has been present, it continues to be monitored and treated. The stability of the condition, along with the active management through medication, signifies that COPD is still relevant to the patient's current health status. In contrast, a history of DVTs, resolved pneumonia, and the early onset of dementia either implies that the condition is not actively being treated, has resolved, or is in a pre-diagnostic phase. Simply having a history does not qualify as a current diagnosis unless there is clear management or ongoing treatment. Thus, the scenario describing COPD illustrates a situation that captures a diagnosis the patient continues to face, necessitating monitoring and care, making it the correct choice.