This document discusses how accurately capturing HCC (Hierarchical Condition Category) codes is important for health plans to receive appropriate reimbursement from Medicare. It notes that physician coding is often incomplete or inaccurate, resulting in lower payments than plans are entitled to. The document provides examples of common HCCs that are overlooked, such as diabetic manifestations. It emphasizes the need for physician education, coding feedback, and tools to help providers properly document and code HCCs. The document offers specific guidelines and examples regarding coding issues like linkage language, clinical specificity, history of diagnoses, and monitoring conditions treated by specialists. The overall message is that with better training and understanding of HCC coding, health plans can receive full reimbursement for the care their providers

1. Getting paid for your
hard work.
Which HCC’s are most often not captured and why.

2. “In 2008 Dr. Marcia Naveh wrote: “Medicare Advantage Plan:
HMO’s, PPO’s, POS and PFFS plans, take a look at the
challenges your Physicians face when documenting and coding
for their Risk Population. Lax coding by physicians hurts
Medicare Advantage Plans.
Health plans participating in managed Medicare have never
experienced as wide a gap between actual and potential
payments as currently exists. Simply stated, Medicare
managed care payments from the Centers for Medicare and
Medicaid Services depend on accurate and complete
diagnostic physician coding.”

3. She continued: “The physician coding that health
plans rely on to set their premium payments
levels is incomplete and inaccurate, and as a
result, many health plans currently receive
dramatically lower premiums than those to which
they are entitled. This doesn’t need to be the
case, however.”
I would ask the Plans now: is this still true?

4. “Managed plans and physicians hoping to receive appropriate
reimbursement with their Medicare advantage populations
are often disappointed. HCCs, the most critical diagnoses to
capture in your risk population, are also often the most
overlooked. Why is that?
They are not on the Provider’s radar.
Why? 1. Lack of education to the Providers.
2. Lack of feedback to the Providers.
3. Lack of proper tools to the Providers.

5. Providers will capture their patient’s diabetes but
they often don’t capture the diabetic manifestations
for which Medicare pays. For example, you won’t be
paid your full reimbursement if coding for 250.40 (DM
with renal manifestations) without the 585.4 (CKD IV).
We will be discussing other common HCCs which are
overlooked and how, with proper education, you can
get paid fully for your hard work.
Are most plans relying on the Providers to document
and code? Or are they relying on coders to extract the
HCC’s? And the coders can only extract what the
Provider documents.

6. Educate your providers on how to code their diabetes
codes and also the diabetic manifestations: those
conditions that are “due to” diabetes.
Certified professional coders on staff can perform this
education. Preferably HCC certified coders. Or are you
using Certified coders already to extract the HCC codes?
Give your providers feedback when they forget to
document the diabetic manifestations [and other ICD-9
codes that risk adjust.]
Give your providers positive feedback when they
REMEMBER to document the diabetic manifestations [and
other ICD-9 codes that risk adjust.]
What tools can you use to help your Providers in capturing
their HCC’s?

7. Let’s start with Diabetes.

8. It is not logical to code 250.00 – Diabetes Mellitus with no
complications, once a patient has a diabetic manifestation.
Often Providers will code 250.00 AND 250.40 – Diabetes
Mellitus with renal manifestations and then forget to
document or to link the renal manifestation to the Diabetes.
The correct coding here for chronic kidney disease, stage IV
due to Diabetes is:
250.40, 585.4.
You will be reimbursed for both the diabetes code and the
diabetic complication.

9. Linkage language is important for Providers to use when
documenting their diabetic patients who suffer
complications “due to” their diabetes.
Linkage language is: Diabetic. Hypertensive. Due to.
Caused by. With.
If you don’t document that the CKD IV is “due to” the
diabetes, the coder is forced to code: 250.00, 585.4.
250.00 hierarches at a lower reimbursement than 250.40.
So you are coding incorrectly for the work you performed
and getting reimbursed at a lower level for the work you
performed.

10. 250.4x
HCC 15
250.7x
HCC 15
250.6x
HCC 16
250.8x
HCC 16
250.5x
HCC 18
250.0x
HCC 19
DM with renal
manifestation
s
DM with
peripheral
circulatory
disorders
DM with
neurological
manifestation
s
DM with other
manifestation
s
DM with
Ophthalmic
manifestatio
ns
DM without
complications
CKD IV, CKD
V, CKD VI
Nephropathy
nephrosis
Gangrene,
Peripheral
angiopathy
Gastroparesis Hypoglycemia
Leg ulcers
Diabetic bone
changes
Retinopathy Can be diet
controlled or
on insulin. It
still risk
adjusts.
All of your diabetic manifestation risk adjust so
it’s important to capture all of them.

11. How do you code Diabetic CKD, PVD and
PN?
250.40, 585.9, 250.70, 443.81, 250.60, 357.2
DM with renal manifestations, CKD, DM with
peripheral circulatory disorders, peripheral
angiopathy, DM with neurological manifestations,
polyneuropathy in diabetes.
HCC’s captured are: 250.40, 585.9, 443.81 and
357.2.
Are you documenting and coding like this in your
Practice?

12. Is your clerical in order so that you can
capture your HCC’s compliantly?
 Signature: must be signed by an allowable Provider type
with credential.
 This includes MD, DO, NP & PA.
 Must be a documented face to face visit.
 Date of Service must be on each page of the patients
chart.
 A Patient identifier must be on each page of the patients
chart. This means their date of birth OR MRN# OR SS#.

13. Assessment and Plan
 Your HCC diagnosis must be documented in your Assessment and
Plan.
 Coders cannot take it from a list of patient conditions,
diagnostic reports, problem lists, lab or radiology reports.
 If the condition is not evaluated and assessed, it cannot be
coded.
 MEAT: Managed, monitored, evaluated, assessed, treated.
 Only 1 or more of MEAT has to be documented. Not all of them.
 We cannot capture an HCC from an ICD-9 code written in the
chart without evaluation and assessment.

14. We can’t capture it from this:
 Problem list: diabetes
 Radiology report: atherosclerosis of aorta
 Lab report: GFR< 60
 250.40 written in chart not but no
assessment or plan documenting it.

15. Clinical specificity
 We are looking for clinical specificity. Only chronic hepatitis B
and C risk adjusts. So if you document “Hepatitis” in your chart
note? We cannot capture the HCC.
 For mental disorders, is it “major” as in Major Depressive
Disorder? Recurrent? Situational? This decides if it risk adjusts
or not. MDD 296.31, recurrent, mild, risk adjusts. Depression:
311 does not risk adjust. Grief reaction 309.0 does not risk
adjust.
 Leukemia’s risk adjust as acute, chronic and even in remission.
So you must be specific in how you document your patients with
leukemia.

16. “History of” is often used incorrectly by Providers.
Here are some examples:
1. “Patient has history of breast cancer. She is on
tamoxifen.”
Incorrect: patient is actively being treated for
her breast cancer so it’s not history of. Capture
174.9 which risk adjusts.
2. “Patient has prostate cancer. Prostate surgery 8
years ago. NED.” Incorrect: patient has “history
of” prostate cancer. So you must code V10.46
which does not risk adjust. If you code 185 and
get paid for it you will be penalized because you
are submitting an HCC that no longer exists.
3. “Patient has prostate cancer. He is currently
taking Lupron.” Now we can code the prostate
cancer code of 185 which risk adjusts.

17. If your diabetic patient has ESRD due to DM and goes on dialysis,
you document this and it is coded as: 250.40, 585.6, V45.11
[renal dialysis status.] 3 codes. Is your Practice doing this?
An HCC that is often documented but not coded is cachexia
799.4. This risk adjusts. You find this most often in your end
stage or cancer patients.
If your patient has hepatitis, cirrhosis or pancreatitis “due to”
alcoholism, you must also code the alcoholism. Even alcoholism
‘in remission’ risk adjusts. Most Providers are not documenting
or coding this. Both drug or alcohol dependence “in remission”
risk adjusts.
A coder can never assume “in remission” vs. “history of” vs.
“current.” Only the Provider knows and can document that. If it
is not documented, you will lose capturing that HCC.

18. PCP’s are currently the gate keepers.
 The PCP can document in his/her chart that his patient,
who has cancer, see’s Dr. X for the condition. The PCP can
document how the patient is doing and what treatment
they are undergoing. This is considering “monitoring”
under MEAT and the coder can then capture that HCC.
 This is a common way for the Provider to capture M.S.,
Parkinson’s and epilepsy that all risk adjust. Use your
monitoring documentation if your patients are seeing a
Specialist for these conditions.

19. Atherosclerosis of the aorta risk adjusts
 440.0 This condition is captured most often in an x-ray
report. Once you see that your patient has this then you
must note in the assessment and plan at least once a year
that they have this condition and it is being monitored or
managed with hypertensive drugs, etc. Then this HCC can
be captured.
 412 Old myocardial infarction. This can be documented
anywhere in the note to be picked up as an HCC.
 413.9 Angina risk adjusts. Don’t just document “chest
pain” if the patient has angina. Nitro in the medicine list
alerts the coder this could be angina.

20. Know your HCC’s. Then document and
code them.
 “The physician coding that
health plans rely on to set their
premium payments levels is
incomplete and inaccurate, and
as a result, many health plans
currently receive dramatically
lower premiums that those to
which they are entitled.”
 Is this still the case?
 This doesn’t have to be the
case. With excellent Provider
training, certified coders on
staff and a healthy
understanding of the necessity
to document and code your risk
adjusted ICD-9 codes,
appropriate reimbursement can
be yours.

21. Deborah McEachern CPC, CHCCS
Head of Product Development for Medical Coding
*iQuartic-Building Healthy Connections
Phone: 617-500-0093 ext. 130
Cell: 970-402-3135