CRC Applying HCCs in Scenarios 2

Question 1

A 72-year-old Medicare Advantage patient is diagnosed with both Type 2 diabetes with diabetic chronic kidney disease stage 3 and diabetic retinopathy.
Which coding approach correctly captures the HCC impact?

Accepted Answer

Code E11.22 and E11.319 separately since each maps to a distinct HCC

Answer

Code only E11.22 for diabetic CKD as it has the highest RAF

Answer

Use only E11.65 as a combination code covering all complications

Answer

Code N18.3 alone since CKD drives the RAF score

Question 2

During a retrospective chart review, a coder finds documentation of 'history of stroke' in a patient's problem list from 3 years ago with no current treatment. How should this be handled for HCC coding?

Accepted Answer

Query the provider to determine if the condition still impacts current care management

Answer

Code Z86.73 as personal history of stroke

Answer

Code I63.9 as the stroke is still relevant for risk adjustment

Answer

Do not code it since strokes older than 2 years are excluded

Question 3

A patient has documentation of moderate persistent asthma with acute exacerbation and chronic obstructive pulmonary disease. What is the correct approach?

Accepted Answer

Apply the HCC hierarchy and code only the condition with the highest RAF value

Answer

Code only J44.1 since COPD with exacerbation subsumes the asthma HCC

Answer

Code J45.41 and J44.1 separately as they map to different HCCs

Answer

Code only J45.41 since asthma with exacerbation has a higher HCC weight

Question 4

A risk adjustment coder is reviewing a chart where the provider documents 'morbid obesity' but the patient's recorded BMI is 37.2. Which action is most appropriate?

Accepted Answer

Query the provider because morbid obesity typically requires BMI of 40 or higher or 35 with comorbidity

Answer

Code E66.01 for morbid obesity since the provider documented it

Answer

Code E66.01 and Z68.37 to capture both the obesity and BMI

Answer

Code E66.09 for other obesity since the BMI does not support morbid obesity

Question 5

A CRC identifies that a patient with known heart failure (HCC 85) also has a new diagnosis of chronic kidney disease stage 4 (HCC 137). What interaction should the coder be aware of?

Accepted Answer

These conditions create an HCC interaction coefficient that increases the combined RAF

Answer

The CKD HCC will subsume the heart failure HCC through disease hierarchy

Answer

Only the most recently diagnosed condition is counted in the current payment year

Answer

These conditions cannot be coded together under CMS-HCC rules

Question 6

A coder is abstracting diagnoses from a specialist consultation note containing code F33.1 for major depressive disorder, recurrent, moderate. The PCP's note lists 'depression' without specificity. Which code should be submitted?

Accepted Answer

F33.1 as the most specific code supported by documentation

Answer

F32.9 as the PCP documentation takes precedence

Answer

Both F32.9 and F33.1 to capture all documented information

Answer

Neither code since the conflicting documentation requires a query