CRC - Certified Risk Adjustment Coder Applying HCCs in Scenarios Questions and Answers

Question 1

A 72-year-old male is seen for management of his chronic conditions.
The physician's assessment documents 'Stage 4 Chronic Kidney Disease' and 'End-Stage Renal Disease (ESRD) on dialysis.' Both conditions are addressed in the plan of care.
How should these diagnoses be coded and considered for CMS-HCC risk adjustment?

Accepted Answer

Code only ESRD (N18.6) because its corresponding HCC takes precedence over the HCC for Stage 4 CKD.

Answer

Code both ESRD and Stage 4 CKD, as both are documented and managed.

Answer

Code only Stage 4 CKD (N18.4) because it is a more specific stage diagnosis.

Answer

Query the provider to clarify which condition is the primary focus of the visit.

Question 2

A 65-year-old female presents for a follow-up on her hypertension. During the encounter, the physician documents that the patient has a 'permanent ileostomy, status post colectomy, functioning well.' The status of the ostomy is evaluated as part of the overall patient assessment. What is the most appropriate coding action for the ileostomy?

Accepted Answer

Report the appropriate artificial opening status code (e.g., Z93.2) as it is a chronic condition affecting patient care and maps to an HCC.

Answer

Do not report the ileostomy status, as it is not the primary reason for the visit.

Answer

Report the underlying reason for the ostomy, which was ulcerative colitis.

Answer

Query the provider to document a complication of the ostomy before it can be coded.

Question 3

A coder is reviewing an outpatient record for an 80-year-old patient. The physician's assessment lists 'Heart failure' and the plan states 'Continue Lasix.' No acuity (acute/chronic) or type (systolic/diastolic) is specified. Which of the following is true regarding HCC capture for this diagnosis?

Accepted Answer

The diagnosis can be coded as I50.9, Heart failure, unspecified, which maps to a payable HCC.

Answer

The diagnosis cannot be captured for risk adjustment because it lacks required specificity like 'systolic' or 'diastolic'.

Answer

A query must be sent to the provider to clarify the type of heart failure before any code can be assigned.

Answer

Only acute or chronic heart failure can be captured for risk adjustment, not an unspecified diagnosis.

Question 4

An 82-year-old male is seen for an annual wellness visit. The problem list includes 'History of lung cancer.' In the HPI, the physician notes, 'Patient had lung cancer treated with resection 6 years ago, no evidence of recurrence, on surveillance only.' The assessment and plan for the visit do not address the cancer. How should the coder report the lung cancer diagnosis for this encounter?

Accepted Answer

Assign code Z85.118 (Personal history of malignant neoplasm of bronchus and lung) as the condition is resolved and not currently being treated.

Answer

Code the active lung cancer, as it is part of the patient's permanent medical history.

Answer

Do not code the cancer in any form, as it was not part of the active assessment and plan.

Answer

Query the provider to confirm if the cancer is considered 'cured' or 'in remission'.

Question 5

A patient record from an annual wellness visit includes documented and managed diagnoses of Type 2 Diabetes without complications (E11.9), Congestive Heart Failure (I50.9), and Chronic Obstructive Pulmonary Disease (J44.9). Assuming all conditions meet MEAT criteria, how are these diagnoses treated in the CMS-HCC model?

Accepted Answer

Each of these diagnoses maps to a separate HCC, and all three can contribute to the final risk score.

Answer

Only the single highest-risk diagnosis (Congestive Heart Failure) will be counted toward the risk score.

Answer

A disease hierarchy applies, and only the Diabetes and CHF are counted.

Answer

Diabetes and COPD are combined into a single cardiorespiratory HCC.

Question 6

A 68-year-old patient with Type 2 diabetes is seen for a worsening foot ulcer. The physician's assessment is 'Diabetic foot ulcer due to diabetic peripheral neuropathy.' Which combination of codes best captures this clinical scenario for accurate risk adjustment?

Accepted Answer

E11.621 (Type 2 diabetes mellitus with foot ulcer) and E11.40 (Type 2 diabetes mellitus with diabetic neuropathy, unspecified).

Answer

E11.9 (Type 2 diabetes mellitus without complications) and a code for the ulcer.

Answer

E11.621 (Type 2 diabetes mellitus with foot ulcer) only, as this is the most specific diagnosis.

Answer

E11.40 (Type 2 diabetes mellitus with diabetic neuropathy, unspecified) and a code for the ulcer.