Certified Risk Adjustment Coder (CRC)

Which item should a coder validate before reporting a diagnosis?

1. The patient’s previous medical history

2. The results of the previous lab work

3. The provider's clinical notes

4. The patient's self-reported symptoms

The correct answer is: The provider's clinical notes

Validation of a diagnosis prior to reporting is a critical component of coding accuracy and compliance. The provider's clinical notes are essential because these documents contain firsthand accounts of the patient's care, assessments made by the healthcare provider, and the rationale for the diagnosis. These notes typically detail the clinical findings, diagnostic testing results, treatment plans, and follow-up information that are necessary for substantiating the diagnosis reported to payers. When coders reference the clinical notes, they ensure that the diagnosis aligns with the documentation provided by the provider. This helps to confirm that the diagnosis is supported by the provider's clinical judgment and encounters, minimizing potential discrepancies that could lead to claim denials or audits. Other options, while providing helpful context, do not serve as critical validation sources for the diagnosis. For instance, the patient's previous medical history or lab results may inform clinical decisions but are secondary to the provider's documentation. Similarly, a patient's self-reported symptoms may not hold the same weight as the clinical assessment performed by a healthcare professional, which is what clinical notes represent in this context. Thus, the provider's clinical notes are the most vital resource for ensuring that the reported diagnosis is accurate and aligned with the provider's findings.