Question

multiple select question

select all that apply

coding diagnoses are based on the providers diagnosis or diagnoses. this information may be located in which of the following documents?

patients statement
encounter form
claim form
progress notes

Explanation:

Analyze the source of provider diagnoses

Medical coding requires official documentation written or signed by the healthcare provider. We must evaluate where a provider's official diagnosis can be found among the choices.

Evaluate each document option

• patient's statement: This contains subjective complaints or history reported by the patient, not the provider's official clinical diagnosis. Thus, it is incorrect.
• encounter form: Also known as a superbill, this form is completed by the provider during the visit and contains the documented diagnoses and procedure codes. Thus, it is correct.
• claim form: This is the billing form (like CMS-1500) sent to insurance. While it contains diagnosis codes, the codes are derived from the provider's documentation; the claim form itself is not the source document where the provider's original clinical diagnosis is recorded. Thus, it is incorrect.
• progress notes: These are the detailed clinical notes written by the provider documenting the patient's encounter, which explicitly include the provider's assessment and diagnoses. Thus, it is correct.

Identify the correct selections

Using the Encounter Form Documentation and Progress Reports concepts, the provider's clinical diagnoses are officially documented in the encounter form and the progress notes.

Answer:

• patient's statement
• encounter form (Correct answer)
• claim form
• progress notes (Correct answer)