Applying HCCs in Scenarios Flashcards
6 cards from real CRC practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 6 Applying HCCs in Scenarios flashcards as text
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?
Answer: Code E11.22 and E11.319 separately since each maps to a distinct HCC
E11.22 maps to HCC 18 and E11.319 maps to HCC 27. These are separate HCCs and both should be coded to capture the full risk profile.
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?
Answer: Query the provider to determine if the condition still impacts current care management
A 'history of stroke' requires a provider query to determine whether the condition is still actively monitored or treated during the current reporting period.
A patient has documentation of moderate persistent asthma with acute exacerbation and chronic obstructive pulmonary disease. What is the correct approach?
Answer: Apply the HCC hierarchy and code only the condition with the highest RAF value
CMS-HCC uses hierarchies where higher-severity conditions within the same disease group subsume lower ones. The coder should code all conditions accurately; the hierarchy is applied during RAF calculation.
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?
Answer: Query the provider because morbid obesity typically requires BMI of 40 or higher or 35 with comorbidity
While the provider documented morbid obesity, the BMI of 37.2 does not automatically support that diagnosis. A query is needed to verify if comorbidities support the morbid obesity designation.
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?
Answer: These conditions create an HCC interaction coefficient that increases the combined RAF
The CMS-HCC model includes disease interaction terms. Heart failure combined with CKD generates additional payment because the combination predicts higher costs than either condition alone.
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?
Answer: F33.1 as the most specific code supported by documentation
F33.1 is the most specific code supported by the specialist's documentation. For risk adjustment, the most specific code from any qualified provider should be used.