Level 1 coding describes encounters in which the diagnosis is made based on clinical examination without laboratory tests or imaging.

• A. Diagnoses are made based on the physical examination without laboratory tests or imaging
• B. Diagnoses are made after laboratory confirmation
• C. Imaging is always required to confirm the diagnosis
• D. The patient is admitted for observation

Answer: (A)

Level 1 coding is about making the diagnosis from the clinical examination alone, without relying on laboratory tests or imaging. This means the clinician forms the working diagnosis based on history and physical findings observed during the visit. The other statements imply reliance on tests or imaging, or concern disposition rather than how the diagnosis was established, which is why they don’t describe Level 1 coding. For example, a simple clinical assessment where a diagnosis is inferred from a physical exam and history (no labs or imaging) fits Level 1, whereas needing lab confirmation or imaging would move beyond Level 1.