CRC - Certified Risk Adjustment Coder Applying HCCs in Scenarios Questions and Answers 1 — 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?
- Code both ESRD and Stage 4 CKD, as both are documented and managed.
- Code only ESRD (N18.6) because its corresponding HCC takes precedence over the HCC for Stage 4 CKD. (Correct answer)
- Code only Stage 4 CKD (N18.4) because it is a more specific stage diagnosis.
- Query the provider to clarify which condition is the primary focus of the visit.
Correct answer: Code only ESRD (N18.6) because its corresponding HCC takes precedence over the HCC for Stage 4 CKD.
The CMS-HCC model uses disease hierarchies to prevent counting multiple codes for the same disease progression. Only the most severe condition in a hierarchy is used for risk score calculation. End-Stage Renal Disease (ESRD) is in a higher-ranking HCC category than Chronic Kidney Disease, Stage 4. Therefore, while both codes are clinically accurate, only the HCC for ESRD will be applied in the payment model.
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?
- Do not report the ileostomy status, as it is not the primary reason for the visit.
- Report the underlying reason for the ostomy, which was ulcerative colitis.
- 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. (Correct answer)
- Query the provider to document a complication of the ostomy before it can be coded.
Correct 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.
Certain 'Z' codes, particularly status codes for conditions that have a long-term impact on a patient's health, are valid for risk adjustment. An artificial opening status, such as an ileostomy (Z93.2), is a chronic condition that requires ongoing monitoring, impacts medical decision-making, and maps to an HCC. As it was evaluated during the visit, it meets MEAT criteria and should be reported.
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?
- The diagnosis can be coded as I50.9, Heart failure, unspecified, which maps to a payable HCC. (Correct answer)
- The diagnosis cannot be captured for risk adjustment because it lacks required specificity like 'systolic' or 'diastolic'.
- A query must be sent to the provider to clarify the type of heart failure before any code can be assigned.
- Only acute or chronic heart failure can be captured for risk adjustment, not an unspecified diagnosis.
Correct answer: The diagnosis can be coded as I50.9, Heart failure, unspecified, which maps to a payable HCC.
While greater specificity is always the goal of clinical documentation improvement, its absence does not automatically prevent valid HCC capture. A documented diagnosis of 'Heart failure' that is being managed (e.g., treatment with Lasix) supports coding I50.9, Heart failure, unspecified. This code is a valid diagnosis and maps to a CMS-HCC, allowing for risk adjustment capture based on the available documentation.
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?
- Code the active lung cancer, as it is part of the patient's permanent medical history.
- Assign code Z85.118 (Personal history of malignant neoplasm of bronchus and lung) as the condition is resolved and not currently being treated. (Correct answer)
- Do not code the cancer in any form, as it was not part of the active assessment and plan.
- Query the provider to confirm if the cancer is considered 'cured' or 'in remission'.
Correct answer: Assign code Z85.118 (Personal history of malignant neoplasm of bronchus and lung) as the condition is resolved and not currently being treated.
For risk adjustment, a diagnosis must be current and meet MEAT (Monitored, Evaluated, Assessed, Treated) criteria for the specific encounter. The documentation clearly indicates the cancer is resolved, not under active treatment, and only subject to surveillance. Therefore, coding it as an active malignancy would be non-compliant. The correct approach is to use a 'personal history of' code (Z85.118), which accurately reflects the patient's condition but does not map to a cancer HCC.
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?
- Only the single highest-risk diagnosis (Congestive Heart Failure) will be counted toward the risk score.
- A disease hierarchy applies, and only the Diabetes and CHF are counted.
- Diabetes and COPD are combined into a single cardiorespiratory HCC.
- Each of these diagnoses maps to a separate HCC, and all three can contribute to the final risk score. (Correct answer)
Correct answer: Each of these diagnoses maps to a separate HCC, and all three can contribute to the final risk score.
The CMS-HCC model is additive, meaning that multiple chronic conditions in different disease categories can each contribute to the patient's overall risk score. Diabetes, Congestive Heart Failure, and COPD belong to separate HCC categories and do not have hierarchies with each other. Therefore, if all are properly documented and managed during an encounter, each would contribute its respective HCC to the risk score calculation, providing a more complete picture of the patient's health complexity.
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?
- E11.9 (Type 2 diabetes mellitus without complications) and a code for the ulcer.
- E11.621 (Type 2 diabetes mellitus with foot ulcer) only, as this is the most specific diagnosis.
- E11.621 (Type 2 diabetes mellitus with foot ulcer) and E11.40 (Type 2 diabetes mellitus with diabetic neuropathy, unspecified). (Correct answer)
- E11.40 (Type 2 diabetes mellitus with diabetic neuropathy, unspecified) and a code for the ulcer.
Correct answer: E11.621 (Type 2 diabetes mellitus with foot ulcer) and E11.40 (Type 2 diabetes mellitus with diabetic neuropathy, unspecified).
To fully capture the patient's disease burden, all documented chronic conditions and complications should be coded. The physician's assessment explicitly links both the foot ulcer and the underlying neuropathy to the diabetes. The code for a diabetic foot ulcer (E11.621) maps to an HCC, and the code for diabetic neuropathy (E11.40) maps to a separate, distinct HCC. Coding both is necessary to accurately represent the patient's complex health status for risk adjustment.
CRC - Certified Risk Adjustment Coder Applying HCCs in Scenarios Questions and Answers 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?