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

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.

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

A 'history of stroke' requires a provider query to determine whether the condition is still actively monitored or treated during the current reporting period.

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

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.

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

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.

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 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.

(CRC) Certified Risk Adjustment Coder Practice Test

(CRC) Certified Risk Adjustment Coder Practice Test

CRC Applying HCCs in Scenarios 2