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

Both the underlying PVD and amputation status should be coded as they map to separate HCCs and provide the complete clinical picture.

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 and Hepatitis C belong to separate HCC hierarchies. Both are counted independently in the RAF calculation.

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

When documentation lacks specificity needed for accurate HCC mapping, the coder should query the provider. Upcoding without documentation support is fraudulent.

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

When multiple diagnoses map to the same HCC, the HCC is counted only once. Both conditions should still be coded for clinical completeness.

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

Any qualifying face-to-face encounter can support an HCC. The most specific code documented across all qualifying encounters determines the HCC captured.

(CRC) Certified Risk Adjustment Coder Practice Test

(CRC) Certified Risk Adjustment Coder Practice Test

CRC Applying HCCs in Scenarios 3