CRC Applying HCCs in Scenarios 2 — Questions and Answers
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?
- Code only E11.22 for diabetic CKD as it has the highest RAF
- Code E11.22 and E11.319 separately since each maps to a distinct HCC (Correct answer)
- Use only E11.65 as a combination code covering all complications
- Code N18.3 alone since CKD drives the RAF score
Correct 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.
In CMS-HCC risk adjustment, each diagnosis code maps to a specific HCC. When a patient has multiple diabetic complications that fall under different HCCs, each must be coded separately to capture the full disease burden and expected costs.
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?
- Code Z86.73 as personal history of stroke
- Code I63.9 as the stroke is still relevant for risk adjustment
- Do not code it since strokes older than 2 years are excluded
- Query the provider to determine if the condition still impacts current care management (Correct answer)
Correct 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.
For risk adjustment purposes, conditions must be documented as actively managed or impacting care decisions during the current encounter year. The coder must query the provider to clarify the clinical status before assigning a code.
Question 3: A patient has documentation of moderate persistent asthma with acute exacerbation and chronic obstructive pulmonary disease. What is the correct approach?
- Code only J44.1 since COPD with exacerbation subsumes the asthma HCC
- Code J45.41 and J44.1 separately as they map to different HCCs
- Code only J45.41 since asthma with exacerbation has a higher HCC weight
- Apply the HCC hierarchy and code only the condition with the highest RAF value (Correct answer)
Correct 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.
When COPD and asthma both map to HCCs within the same hierarchy, the model automatically applies the higher-value HCC. Both conditions should still be coded accurately — the hierarchy is applied during RAF calculation, not during coding.
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?
- Code E66.01 for morbid obesity since the provider documented it
- Code E66.01 and Z68.37 to capture both the obesity and BMI
- Query the provider because morbid obesity typically requires BMI of 40 or higher or 35 with comorbidity (Correct answer)
- Code E66.09 for other obesity since the BMI does not support morbid obesity
Correct 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.
Morbid obesity (E66.01) maps to HCC 22 and carries significant RAF weight. A BMI of 37.2 falls in class II obesity range, not class III. The coder must query to determine if comorbidities support the morbid obesity designation.
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?
- These conditions create an HCC interaction coefficient that increases the combined RAF (Correct answer)
- The CKD HCC will subsume the heart failure HCC through disease hierarchy
- Only the most recently diagnosed condition is counted in the current payment year
- These conditions cannot be coded together under CMS-HCC rules
Correct 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.
When both HCCs are present, an interaction coefficient is added to the RAF score on top of the individual HCC weights. Accurate capture of both conditions is especially important to avoid losing the interaction bonus.
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?
- F32.9 as the PCP documentation takes precedence
- F33.1 as the most specific code supported by documentation (Correct answer)
- Both F32.9 and F33.1 to capture all documented information
- Neither code since the conflicting documentation requires a query
Correct 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.
Any documentation from a qualified provider during an acceptable encounter type can be used. The specialist's more specific documentation ensures accurate risk capture without overcoding.
CRC Applying HCCs in Scenarios 2
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?