Certified Risk Adjustment Coder (CRC)

Which statement about reporting diagnosis codes is true?

1. Diagnosis codes are required for conditions documented in the assessment only

2. Diagnosis codes can be reported only for conditions in the treatment plan

3. Diagnosis codes can be reported for all active conditions in the medical record

4. Diagnosis codes are needed only if confirmed by diagnostic tests

The correct answer is: Diagnosis codes can be reported for all active conditions in the medical record

The statement that diagnosis codes can be reported for all active conditions in the medical record is accurate because coding guidelines and practices emphasize the need to document and code for all active diagnoses that impact patient care or treatment. This includes not just conditions currently being treated, but also those that may influence management and care decisions, even if they are not the primary focus of treatment. Active conditions encapsulate a broad range of situations, such as chronic illnesses that require ongoing management or monitoring, conditions that may impact the patient's overall health, and any issues that arise during the patient encounter. This comprehensive coding approach ensures that healthcare providers accurately reflect the patient's health status and the complexity of care delivered, which is essential for appropriate reimbursement and to maintain a thorough medical record. In contrast to the other statements, which suggest limitations on what can be reported, the true scope of diagnosis coding supports full documentation of all relevant active conditions to provide a holistic view of the patient's healthcare needs.