Certified Risk Adjustment Coder (CRC)

Which statement from the ROS can be reported as a current diagnosis?

1. Patient states she feels anemic.

2. Respiratory: asthma-uses rescue inhaler once per week.

3. Cardiovascular: patient notices a rapid rate at night.

4. Constitutional: patient had a fever for the last two days.

The correct answer is: Respiratory: asthma-uses rescue inhaler once per week.

The statement that can be reported as a current diagnosis highlights a patient's ongoing condition and treatment. The mention of asthma and the fact that the patient uses a rescue inhaler once per week clearly indicates a chronic respiratory condition that requires management. This aligns with how chronic illnesses are documented and coded. A current diagnosis usually refers to a condition that is actively being managed or treated, and asthma fits this definition as it often necessitates regular medication and monitoring. Utilizing a rescue inhaler is part of the management plan for asthma, making it pertinent to report this as a current diagnosis. In contrast, the other statements provide information on symptoms or past events rather than ongoing conditions. For instance, feeling anemic or having fever for a short duration does not specify an active diagnosis or management. Noticing a rapid heart rate at night also implies a symptom that may need further evaluation, but without additional details, it does not establish a diagnosis in the same way asthma does in the correct answer.