CRC Applying HCCs in Scenarios 3

Question 1

A Medicare Advantage patient's encounter note documents bilateral below-knee amputations secondary to peripheral vascular disease. Which approach is correct?

Accepted Answer

Code I70.269 for atherosclerosis with gangrene and Z89.519 for amputation status

Answer

Code only Z89.519 for acquired absence of both legs

Answer

Code only I70.269 since the underlying disease subsumes the amputation HCC

Answer

Code Z87.39 for personal history of amputation

Question 2

A coder encounters a patient with both hepatitis C (HCC 29) and HIV (HCC 1). Both are documented as active. How does the CMS-HCC model handle this?

Accepted Answer

Both HCCs are counted independently since they belong to separate disease hierarchies

Answer

HIV supersedes hepatitis C through the infectious disease hierarchy

Answer

Only the condition diagnosed first in the payment year is counted

Answer

A disease interaction term reduces the combined RAF

Question 3

A provider documents 'protein-calorie malnutrition' without specifying severity. What should the coder do?

Accepted Answer

Query the provider for severity specification before assigning a code

Answer

Code E46 for unspecified protein-calorie malnutrition as documented

Answer

Code E43 for severe malnutrition since the term implies severity

Answer

Code E44.1 for mild malnutrition as the safest assumption

Question 4

A patient has major depressive disorder (HCC 59), drug use disorder (HCC 55), and alcohol use disorder (HCC 55). How does this affect the RAF?

Accepted Answer

Only one HCC 55 value is counted regardless of how many conditions map to it

Answer

Each diagnosis adds a separate RAF increment even though they share an HCC

Answer

The condition with the most recent encounter date determines the HCC 55 value

Answer

Both substance use disorders are dropped because they create a duplicate HCC conflict

Question 5

A CRC reviews charts where a patient was seen in January for COPD management and in September for a COPD exacerbation. Which encounter drives the HCC assignment?

Accepted Answer

Both encounters support the COPD HCC but the most specific code from either is used

Answer

Only the January encounter since it was first in the payment year

Answer

Only the September hospitalization since inpatient overrides outpatient

Answer

The encounter with the highest E/M level determines HCC eligibility

Question 6

In applying HCCs for a dual-eligible patient (Medicare and Medicaid), what additional factor must the coder consider?

Accepted Answer

The CMS-HCC model applies a dual-eligible interaction factor that modifies certain HCC weights

Answer

Dual-eligible patients require separate HCC submissions to each program

Answer

Medicaid diagnoses cannot be used for Medicare risk adjustment

Answer

Dual-eligible status has no impact on HCC assignment or RAF calculation