HCC CODING training manual

HCC Training Manual

Index
•Introduction
•Benefit to the MA Organization and Physician
•Medicare Advantage Part A, B, C & D
•Introduction to Medicare Advantage Part C
•Introduction to Medicare Advantage Part D
•Risk Adjustment
•Hierarchical Condition Category
•Revised 2014 Risk Adjustment Payment Model
•Example of HCC and ICD-9 Code Mapping
•Risk Score
•Coding Exclusions
•Acceptable Physician Specialty Types
•General Guidelines
•General Medical Record Documentation Considerations
•Valid Provider Signature

Index
• Date of Service
• Record Types
• Format of Records
• M.E.A.T
• Medications as MEAT
• Coding Guidelines per Section of E&M Documentation
• Miscellaneous Coding Guidelines
• Condition specific coding guidelines
• Critical conditions coding guidelines
• CMS Documentation Signature Requirement
• Valid Documents
• Invalid Documents
• Documentation Tips
Clinical Specificity in Documentation
• Documentation Considerations
• Medical Record Issues

INTRODUCTION
•In 2004 Medicare implemented an HCC (Hierarchical Condition Categories) model
to adjust capitation payments to private health care plans for the health
expenditure risk of their enrollees.
•The Centers for Medicare and Medicaid (CMS) Risk Adjustment Model measures
the disease burden that includes 70 HCC categories, which are correlated to
diagnosis codes.
•Medicare Advantage Plans have to submit the "one best medical record" that
supports each beneficiary HCC identified for validation.
•The MA plan can choose to submit
–hospital inpatient,
–hospital outpatient,
–Or physician medical record when more than one option is available.

INTRODUCTION
•Medicare uses ICD-9-CM as the official diagnosis code set for all lines of business
including determination of risk adjustment factors.
•MA organizations must:
–Implement procedures to ensure that diagnoses are coming from physician,
hospital inpatient, or hospital outpatient provider types.
–Submit all relevant ICD-9-CM diagnosis codes for each beneficiary.
–Submit unique diagnoses at least once during the risk adjustment data
reporting period.
•The source medical record documentation that supports each coded diagnosis
must be obtainable and demonstrate adherence to official coding guidelines.
•Relevant diagnoses are defined as those diagnoses collected from one of the three
provider types that are used in the Risk Adjustment models (i.e., CMS-HCC, ESRD
and RxHCC models).

Benefit to the MA Organization and
Physician
A basic understanding of ICD-9-CM process and guidelines assists MA organizations in:
•Interpreting and designing management reports.
•Determining possible causes of ICD-9-CM errors.
•Communicating diagnosis-related collection issues to the provider staff. Developing and
maintaining information systems that meet the clinical data collection needs of the
organization.
•Understanding clinical issues important to beneficiaries.
•Planning for future MA organization services.
Medical record documentation and coding impact several issues important to the physician and
MA organization including:
•Accurate reimbursement.
- ICD-9-CM codes are the basis of the Risk Adjustment models.
- Accurate diagnosis codes are a result of clear, consistent, and complete documentation.
- CMS may verify the accuracy of the diagnoses submitted relative to the medical record
documentation.
•Communication among all members of the health care team.
•Evaluation of the care provided.
•Research and education.
•Practice patterns.

Medicare Advantage Part A, B, C & D
Medicare is a federal health insurance program & consists of 4 parts:
Part A
•IP hospital, IP SNF care, IP care in religious non-medical health care facility, home
health, hospice
Part B
•Doctor services, office visits, screenings, therapies, preventive services, OP
hospital, emergency care, ambulance, medical/surgical supplies and durable
medical equipment

Part C (Medicare Advantage)
•Part A & B services
•Additional services

Part D
•Pharmacy benefits
•Includes plans with varying out-of-pocket requirements

Introduction to Medicare Advantage
Part C
Part C (Medicare Advantage)

Includes Part A and Part B services, includes coverage for extra dental, vision,
hearing and preventive services and some optional supplement services (e.g. gym
memberships and exercise classes)
Medicare Advantage plan receives payment for each member from CMS
Payment is based on member predicted health status and demographic
characteristics
Medicare Advantage plan regulated by CMS

Introduction to Medicare Advantage
Part D
Part D (Prescription Drug Plans)

•Pharmacy benefits
•Offered by Part D plans (PDPs) and MA health plans that offer Part D prescription
drug benefits (MAPDs)
•Includes plans with varying out-of-pocket requirements
•CMS regulated

Risk Adjustment
•Medicare risk adjustment is the term for how Medicare pays Medicare Advantage
(MA) Plans. MA plans are paid based on the member’s diagnoses codes that map
to a Hierarchical Condition Category (HCC). These HCC-related diagnoses codes are
reported by the MA Plan to CMS.

Hierarchical Condition Category
Category of medical conditions that map to a corresponding group of ICD-9 diagnosis
codes. 3,100 ICD-9 codes map to 1 of 70 HCCs

There is a specific ICD-9-CM code for each illness. Only a small number of diagnosis
codes are part of the HCC Payment Model. Eligible diagnosis codes must be
reported to CMS at least once during each calendar year for Risk Adjusted
payment.

Rx HCC- Some HCC codes adjust risk due to prescription burden of disease

Disease Groups/HCCs

ICD-9 codes are grouped together based on diagnosis that are clinically related and
have similar projected costs.

Revised 2014 Risk Adjustment
Payment Model
•Increased number of HCCs from 70 to 79
•Addition of BMI as an HCC
•Removed HCCs for CKD stages 1-3, neuropathy, old MI, etc.
•Significant changes to the HCCs for Diabetes
- Acute complications (250.1x – 250.3x) map to HCC 17
- Chronic complications (250.4x – 250.9x) map to HCC 18

Example of HCC and ICD-9 Code
Mapping
ICD9 ICD-9-CM Description
2013 Payment
HCC
2014 Payment HCC
2013 Payment
RxHCC
2014 Payment RxHCC
042 Human immuno virus dis1 1 1 1
20400 Ac lym leuk wo achv rmn7 8 11 11
25000 DMII wo cmp nt st uncntr19 19 15 15
25060 DMII neuro nt st uncntrl16 18 14 14
2724 Hyperlipidemia NEC/NOS

23 23
27801 Morbid obesity

22 21 21
5851 Chro kidney dis stage I131

125 125
4540 Leg varicosity w ulcer 107

2875 Thrombocytopenia NOS

48

V8541 BMI 40.0-44.9, adult

22 21 21
412 Old MI
83
89 89

Risk Score
•A Risk Score is created in order to determine how an average member in the
population compares to another member in the population.
•The formula reads:
–Risk Score = (demographics) + (disease) + (disease) + (disease).
•Each disease has an HCC risk factor score by CMS. HCC's lump 3,100 diagnoses
from the ICD-9-CM system into about 70 diagnostic groups. In addition, each
member is assigned a demographic risk factor by CMS based upon their
demographics (e.g., age, gender, Medicaid status, original Medicare entitlement
and disability status).
•Total payment to the MA Plan starts with the base payment which is calculated by
the MA Plan and submitted to CMS for approval as part of the Plan’s annual bid
process.
•The total payment calculation is:
–Total Payment = Base Payment x Risk Score

Coding Exclusions
Documentation acceptable for risk adjustment should be from a face-to-face visit. Do
not code the following:
Exclusions – Do Not Code
Lab Phone calls / case manager
visit
Dialysis
Radiology Physician orders Prosthetics/orthotics
Ambulance Charge slips/Superbills Ambulatory surgery center
DME/Supplies Rx scripts Letters not for a face-to-face
visit
Diagnostic/Electro-diagnostic
Reports
Nursing notes/Nurse Only
Visits
Consultation requests
Chemotherapy only Infusion Therapy Visits between provider and
family
Skilled Nursing Facility (SNF)
Nurse visit
Hospital progress note
ICU visit

Acceptable Physician Specialty Types
Code Specialty CodeSpecialty Code Specialty
1 General practice 25 Physical Medicine and rehabilitation 67 Occupational Therapist
2 General Surgery 26 Psychiatry 68 Clinical Psychologist
3 Allergy/Immunology 27 Geriatric Psychiatry 72 Pain Management
4 Otolaryngology 28 Colorectal Surgery 76 Peripheral vascular disease
5 Anaesthesiology 29 Pulmonary Disease 77 Vascular Surgery
6 Cardiology 33 Thoracic Surgery 78 Cardiac surgery
7 Dermatology 34 Urology 79 Addiction Medicine
8 Family Practice 35 Chiropractic 80 Licensed Clinical Social Worker
9 Interventional Pain Management 36 Nuclear Medicine 81 Critical Care (intensivists)
10 Gastroenterology 37 Pediatric Medicine 82 Hematology
11 Internal Medicine 38 Geriatric Medicine 83 Hematology/Oncology
12 Osteopathic Manipulative Medicine39 Nephrology 84 Preventive Medicine
13 Neurology 40 Hand Surgery 85 Maxillofacial Surgery
14 Neurosurgery 41 Optometry 86 Neuropsychiatry
15 Speech Language Pathologist 42 Certified Nurse Midwife 89 Certified Clinical Nurse Specialist
16 Obstetrics/Gynaecology 43 Certified Registered Nurse Anaesthetist90 Medical Oncology
17 Hospice and Palliative Care 44 Infectious Disease 91 Surgical Oncology

General Guidelines
Capture of Diagnoses per Calendar Year
–Coders will review every DOS, however will only capture and report CMS HCC
& RX HCC diagnoses one time within the measurement year
Capture of ‘Best DOS’
–Coders will code the’ Best DOS’ documented within the image. The ‘Best DOS
‘is identified as the DOS that lists all possible HCCs within each reporting
period and adheres to all CMS signature and credential guidelines.
Code each unique Dx though it pops up same HCC (530.81, 530.85 – triggers same Rx
HCC but still can be coded.)

Follow 2013_2014 HCC_RxHCC crosswalk in order to look up for chronic, acute chronic
and acute condition list.

General Medical Record
Documentation Considerations
1.Please make sure to carefully review each record. Please ensure that each of the
following rules is met when reviewing the medical record for HCC validation.
1.Each coded DOS should be able to stand on its own for HCC validation.
1.CMS recommends that patient name and DOS appear on each page of the
medical record. However, if the patient name and DOS are not on each page of
the record, the record will be acceptable for coding as long as it is clear that each
page of the record is for the same patient and same DOS. The coder should
carefully review the entire record for context and should use best judgment.
1.Conditions coded must be stated in the medical record using text (i.e. conditions
documented using only the numerical codes (296.32) are not acceptable for risk
adjustment per CMS)
1.Reported conditions must be supported with medical record documentation.
1.Documentation must demonstrate MEAT (subject to exceptions noted in the
Coding Manual).

General Medical Record
Documentation Considerations
1.Each encounter must be from an acceptable place of service: inpatient hospital,
outpatient hospital or physician’s office visit.
1.Each physician record must be from an acceptable provider type (see table of
acceptable providers on previous pages).
1.Each physician or outpatient hospital encounter must be from a face-to-face
visit.
1.Each record must comply with CMS signature and credential requirements.
1.Characteristics for acceptable documentation include:
•Clear
•Concise
•Consistent
•Complete
•Legible

Date of Service
•DOS must be clear and legible (month, day, and year). CMS requires valid DOS for
each encounter in the medical record for HCC validation.
•If the DOS is not clear and legible do not code the record. Do not guess or use
1/1/YYYY with the E&O for a record which does not contain a clear and legible
DOS.
•Please exercise extreme caution when entering the correct year (e.g. 2013, 2014,
etc).

RECORD TYPE
PHYSICIANS:
1.Followup visit
2.Return visit
3.Office visit
4.IP Consult, IP OP reports – If discharge summary or Discharge date not given, then code seperately and
use Record type as Physican.
5.Opeative procedures done in Medical centers or Physician offices.
INPATIENT:
1.Discharge summary given with Admission and Discharge date.
2. All operative reports, consultation ,inpatient progres notes, colonoscopy reports found within the same
day inpatient visit should be clubbed together with discharge summary and coded in a single visit.
3. Discharge date found in any of the Inpatient document is acceptable for DOS
4. In ED visit DOS was not given but Admit and Discharge date was found please do not consider a ED visit as
valid document.
OUTPATIENT:
1.Same day Admit and Discharge
2.Emergency Department
3.Operative procedures done in Hospital setting
4.Encounter information itself given as "Type – OP"

Format of Records
Conditions can be coded from any part of the record provided the condition is documented
appropriately with MEAT. Documentation is often found in many different formats but the
two most common are:
SOAP format:
•Subjective - HPI, Chief Complaint (patient’s own words), ROS, usually the reason for the
visit is found here
•Objective – Physical exam, review of systems, vitals, weight etc.
•Assessment – Final impression, symptoms, relevant concurrent problems
•Plan - Refill meds, order test, refer to specialists, order lab work, treatment plan
CHEDDAR format:
•Chief Compliant – Presenting problem(s) patient’s own words
•History – Social, medical, surgical, family histories
•Exam – Physical examination of the patient
•Details of Problem – Details of the complaints or symptoms
•Drugs/Dosages – Current medications and dosages
•Assessment – An assessment of the diagnostic process and final impressions
•Recommendations – Return to clinic, refer to specialist, treatment plan
Please keep in mind that not all records follow these formats. The main goals are to verify that
each encounter is a face-to-face visit, with an acceptable provider, and that the conditions
coded have MEAT to support them within the documentation.

M.E.A.T
•All diagnoses codes on physician/OP records must have MEAT to be considered
acceptable for risk adjustment. This would include inpatient consults, inpatient
progress notes (coded as physician records), and ER visits on the day of admission
which are reviewed under the outpatient coding guidelines.
•For physician and OP records, DO NOT CODE conditions which are not definitive
such as: probable, possible, questionable, rule out, likely, or other uncertain
language. Rather, code the condition(s) to the highest degree of certainty for that
encounter/visit, such as symptoms, signs, abnormal test results, or other reason
for the visit.

M.E.A.T
M.E.A.T can be found in any section of the physician/outpatient record. Use coding
judgment to determine acceptable sources of support within each document.

•Monitored (e.g., ordered labs or diagnostic radiology)
•Evaluated (e.g., review lab or x-ray results, physical examination)
•Addressed/Assessed (e.g., condition described as “stable” or “improving”)
•Treated (e.g., referring patient to see a specialist, prescribing or refill of meds,
surgery)
Following can be considered as MEAT:
•Diagnostic studies
•Lab reports
•Symptoms as meat for conditions
•Medications

MEAT
Meat Words (Diagnosis should listed in Impression, HPI, Physical examination)
•Stable Mild
•Improving Asymptomatic
•Worsening Compensated
•Referred to Providers Severe
•Diagnosis linked to medication Persistent
•Controlled Permanent
•Uncontrolled No signs & symptoms
•Likely elevated New onset
•At goal Referred for surgery
•No change Unchanged
•No associated orders are given Well regulated
•No improvement Progression
•Not changed from previous visit

Medications as MEAT
The medications listed in current medication list / Assessment & Plan may be used as
MEAT to code the conditions even if there is no clear documented link in the
medical record.
Few Examples:
Condition Documented Current Medication List
Diabetes Insulin, glucophage, glyburide, Actos, glipizide,
Januvia, Byetta, metformin
Atrial Fibrillation Coumadin, warafin, digoxin
CHF- congestive heart failure Lasix, furosemide, digoxin
COPD – chronic obstructive pulmonary
disease
Albuterol, Flovent, Spiriva, Ipratropium, Atrovent,
Advair

Coding Guidelines per Section of E&M
Documentation
History of Present Illness(HPI)
–Conditions in the HPI will be captured and reported if the diagnosis is
documented as being present at the time of the visit.

Problem Lists (Separate from PMH lists, these can include, but are not limited to,
Active Problems, Chronic Problems, Current Problems, Problems, Ongoing
Problems)
–Code only if there is evidence of MEAT for a chronic diagnosis, acute/chronic
diagnosis from the Problem List.
–The following diagnoses are always coded, regardless of the evidence of MEAT
criteria in the DOS:
•Old Myocardial Infarction
•Amputations
•Transplant Status
•HIV/AIDS

Coding Guidelines per Section of E&M
Documentation
PMH (Past Medical History) Lists or diagnoses noted as a “history of”
•Code the chronic conditions directly from the PMH List without looking for MEAT.
For acute/chronic diagnosis conditions look for MEAT. The following diagnoses are
always coded and released, regardless of the evidence of MEAT criteria in the
DOS:
•Old Myocardial Infarction
•Amputations
•Transplant Status
•HIV/AIDS

ROS (Review of Systems)
•These conditions will be captured and reported directly. The provider is noting
issues or conditions as part of the visit, therefore assessing the systems of the
body.

Coding Guidelines per Section of E&M
Documentation
Physical Exam
–These conditions will be captured and reported.

Assessment/Plan
–Chronic conditions, acute conditions & acute/chronic conditions will be
captured directly without MEAT and reported.

–Diagnoses in the assessment section should be coded unless they are one of
the “special” coded conditions: Cancers, MI, CVAs, fractures etc

Miscellaneous Coding Guidelines
Physical Therapy/ Rehab Therapy/ Occupational Therapy:

•Please code the first DOS, then read carefully through the remaining DOSs for
continuous therapy and add an additional DOS only when a new ICD is found.
There is no need to code all DOSs of a specific period of therapy if all of them have
the same dx.

Miscellaneous Coding Guidelines
Regarding Scribe Utilization:
•CMS offered the following guidance to contractors when reviewing E&M services
when documented by scribes in the medical record.
•If ancillary staff is present while the provider is gathering further information
related to the patient’s visit, he or she may document (scribe) what is dictated and
performed by the physician or NPP.
•The provider needs to review the information as it is written, documented,
recorded, or scribed. The provider also needs to write a notation that they
reviewed the documentation for accuracy (add to it if supplemental information is
needed) and sign his/her name.
•The name of the scribe must be identified in the medical records. Note that
although not required, the date of the signature should be noted.
•Ancillary staff does not need to be employed by the physician (example: hospital
employee) in order to fill the scribe role.

Miscellaneous Coding Guidelines
Abbreviations:

•Ensure that abbreviations are used in proper context. The coder should able to
read the entire record to determine the context.

•If you cannot determine the meaning of the abbreviation, or if it’s not legible, do
not code it.
•Examples of abbreviations that have multiple meanings:

–MI: mitral insufficiency; mental illness; myocardial infarction
–PDR: physicians’ desk reference; proliferative diabetic retinopathy, patient’s dining room
–PMI: past medical illness; point of maximal impulse; posterior myocardial infarction
–PMR: polymyalgia rheumatica; pacemaker rhythm; prior medical record
–PVD: peripheral vascular disease, posterior vitreous detachment

Miscellaneous Coding Guidelines
Coding Strategy:

Code all documented conditions that co-exist at the time of the encounter that
require

• Patient care
• Treatment
• Management

Do not code conditions that were previously treated and no longer exist

Miscellaneous Coding Guidelines
Combinations in Coding:

A combination code is a single code used to classify
–Two diagnoses
–A diagnosis with an associated secondary process
–A diagnosis with an associated complication

Identified by referring to sub-term entries in the Alphabetic Index and by reading the
inclusion and exclusion notes in the Tabular List

Assign only the combination code when that code fully identifies the diagnostic
condition involved. Secondary codes may be necessary

Miscellaneous Coding Guidelines
Signs & Symptoms:
•Acceptable to code when a definitive diagnosis has not been established (usually
do not risk adjust)
•Not acceptable when they are integral to the disease process
•Associated signs and symptoms that are not integral to a disease process should
be coded
•Most found in 780.0-799.9
Legibility:
These elements must be clear:
–Date of Service mm/dd/yyyy
–Patient’s name
–Diagnosis with supporting MEAT

Do not guess, if unsure:
–Have supervisor review
–If completely illegible do not code

Miscellaneous Coding Guidelines
Date of Service:
For each individual Date of Service ensure that the following are met,

1.Does the member name and DOB on the tool match the patient name and DOB on
the medical record?
2.Is the record for the Date of Service legible? (Name, DOS, dx, and MEAT)
3.Is the record from a face-to-face visit?
4.Is the record from an acceptable provider type?
5.Is the record for the Date of Service signed with provider signature and
credentials?
6.Has the Date of Service been entered correctly on the tool?
7.Are the page numbers noted correctly on the tool for the DOS? Code all valid
diagnoses in the medical record. Ensure that all HCC’s are supported with MEAT.

Miscellaneous Coding Guidelines
Chronic Conditions:
The following Conditions must follow supportive document to code as current
conditions
–Cancer
–Fracture
–AAA
–CVA
–Acute MI
–DVT
–P.E
–Sepsis
–Malignant Hypertension
–S.S.S
–Complication codes

Miscellaneous Coding Guidelines
CMS chronic conditions
The following conditions can be coded anywhere from the record without looking for
MEAT.
–DM
–COPD
–CHF
–A-fib
–Multiple Sclerosis
–Hemiplegia
–RA
–Parkinsonism

Miscellaneous Coding Guidelines
A Documentation Strategy:
All encounters must contain
–Patient Name & DOB on every page
–Date of Service
–Signature of provider + credentials
–Compliant signatures (authenticated electronic signatures or original
signatures-typed or stamped signatures not acceptable)
–Document to highest specificity

CONDITION SPECIFIC CODING
GUIDELINES
1.Hypertension & CKD (HCC Categories 80, 131):
Fourth digit indicates malignant (40X.0) or benign (40X.1), and unless documented
with these terms must code 40X.9 (Unspecified)

–Benign HTN is essential hypertension, usually chronic, asymptomatic and
without target organ damage
–Malignant HTN is an accelerated hypertensive disorder, with diastolic BP
usually >140 and accompanied by encephalopathy, nephropathy, retinopathy,
heart failure or myocardial ischemia
–Controlled or Uncontrolled? Indicates clinical response to treatment, but does
not differentiate between benign and malignant type

Elevated blood Pressure does not code to hypertension-use 796.2

CONDITION SPECIFIC CODING
GUIDELINES
How is HTN related to Heart and Kidney Disease?

Elevated BP increases pressure in the blood vessels, causing thickening over time.

As the heart pumps against this pressure, it must work harder. This increased work
causes the heart muscle to thicken, eventually leading to congestive heart failure if
not treated.

The thicker heart muscle needs more oxygen, and insufficient oxygen can lead to
ischemia (angina)

Thickening of the blood vessels may worsen atherosclerosis. This is most damaging to
the smallest blood vessels, such as in the heart and kidney, leading to damage of
these end organs

CONDITION SPECIFIC CODING
GUIDELINES
Systolic & Diastolic Heart Failure:

•Systolic HF- a pumping problem caused by the ventricle losing its ability to contract
normally because the heart muscle has become weak

•Diastolic HF is the result of a filling problem, caused by the ventricle losing its
ability to relax normally because the heart muscle has become stiff. The heart
can’t fill with enough blood resulting in too little blood being pumped back out
into the body

•Most patients have a combination of both; usually classified as whichever is worst

CONDITION SPECIFIC CODING
GUIDELINES
HTN & Heart Disease:

•Documentation must state a causal (‘due to’ or ‘secondary to’), or implied (using
the adjective ‘Hypertensive’) relationship between HTN and Heart Disease –it is
not assumed

– Hypertensive CHF 402.91 & 428.0
– Hypertensive HF 402.91 & 428.0
– HTN due to CHF 402.91 & 428.0
– HF due to HTN 402.91 & 428.9

•Dual code requirement of 402.XX and Heart Disease code.
•More than one code from category 428 may be assigned

CONDITION SPECIFIC CODING
GUIDELINES
HTN LINKED HEART DISEASE w/CHF
•REQUIRES TWO CODES-ONE EACH FROM HTN HEART DZ AND CHF
•HCC CHF UNSPECIFIED 428.0
•HCC LEFT HEART FAILURE 428.1
•HCC SYSTOLIC-UNSPEC 428.20
•HCC SYSTOLIC-ACUTE 428.21
•HCC SYSTOLIC-CHRONIC 428.22
•HCC DIASTOLIC-UNSPEC 428.30
•HCC DIASTOLIC-ACUTE 428.31
•HCC DIASTOLIC-CHRONIC 428.32
•HCC COMBINED-UNSPEC 428.40
•HCC COMBINED-ACUTE 428.41
•HCC COMBINED-CHRONIC 428.42
•HCC HEART FAILURE UNSPECIFIED 428.9
HYPERTENSIVE HEART DISEASE (HCVD)
•RX ONLY BENIGN W/O HF 402.10
•RX ONLY UNSPEC HTN W/O HF 402.90
•RX ONLY MALIGNANT W/O HF 402.00
•HCC **BENIGN W/CHF 402.11
•HCC **UNSPEC HTN W/CHF 402.91
•HCC **MALIGNANT W/CHF 402.01

CONDITION SPECIFIC CODING
GUIDELINES
Chronic Kidney Disease (CKD):

•Four digits-the fourth indicates stage of disease. Stage 1&2 need additional evidence of
•Kidney damage, such as urine protein that persists for 3 months or more, ultrasound or biopsy
•Documentation must include stage, or is coded as 585.9 CKD unspecified

Dialysis

•Hemodialysis is the process of filtering the patient’s blood through a machine. Performed either as outpatient or
inpatient
•Peritoneal dialysis uses the patient’s abdominal lining to remove toxins. Usually performed in the patient’s home.
Staging CKD
Stage Severity GFR Value ICD-9
Stage 1 some kidney damage with minimal or slight change in GFR (GFR >90 ml/min) with kidney damage - 585.1
Stage 2 Mild Kidney damage (GFR 60-89 ml/min) with kidney damage - 585.2
Stage 3 Moderate Kidney damage (GFR 30-59 ml/min) - 585.3
Stage 4 Severe Kidney damage (GFR 15-29 ml/min) - 585.4
Stage 5 Kidney Failure (GFR < 15 ml/min) - 585.5
ESRD Requiring chronic dialysis or transplantation - 585.6
CKD Unsp. CKD NOS, Chronic Renal Failure or Chronic Renal Insufficiency - 585.9

CONDITION SPECIFIC CODING
GUIDELINES
HTN & CKD **REQUIRES TWO CODES-ONE FROM HTN DZ AND CKD:

•RX ONLY BENIGN W/CKD (STAGE I-IV) 403.10
•HCC BENIGN W/CKD V-ESRD 403.11
•RX ONLY UNSPEC W/CKD (STAGE I-IV) 403.90
•HCC UNSPEC W/CKD V-ESRD 403.91
•RX ONLY BEN W/O HF W/CKD ST I-IV 404.10
•HCC BEN W/O HF W/CKD ESRD 404.12
•RX ONLY UNSPEC W/O HF W/CKD I-IV 404.90
•RX ONLY MALIGNANT W/CKD (ST I-IV) 403.00
•HCC MAL W/O CHF W/CKD ESRD 404.02
•HCC MALIGNANT W/CKD V-ESRD 403.01
•
CHRONIC KIDNEY DISEASE (CKD)

•HCC CHRONIC STAGE 1 GFR>90 585.1
•HCC MILD STAGE 2 GRF 60-89 585.2
•HCC MOD STAGE 3 GFR 30-59 585.3
•HCC SEVERE STAGE 4 GFR 15-29 585.4
•HCC 5 GFR <15 585.5
•HCC ESRD W/DIALYSIS 585.6
•HCC CKD UNSPEC, CRF 585.9
•HCC RENAL DIALYSIS STATUS V45.11

CONDITION SPECIFIC CODING
GUIDELINES
ESRD Coding:

•Dual code requirement for patient on dialysis
585.6 ESRD
V45.11 Renal Dialysis status
•ESRD on Hemodialysis due to Diabetes
250.40
585.6
V45.11

CKD and HTN (403.XX):

•Relationship may be assumed between these conditions if both are reported
•Dual code required when 403 series is used, indicating the related CKD (585.x)

–– Hypertensive* CKD Stage 4 - 403.90 & 585.4
–– HTN & ESRD on dialysis (CKD Stage 6)-403.91 & 585.6 & V45.11

•Even though coders may assume this relationship, coach providers to use the adjective form of the
diagnosis

CONDITION SPECIFIC CODING
GUIDELINES
Hypertensive Heart & Kidney (404.XX):

•Both hypertensive kidney disease and hypertensive heart disease must be stated,
although the relationship between hypertension and the CKD is assumed
•Any hypertensive heart disease is acceptable, not just HF

•5th digits are assigned
–0 without HF and with CKD Stage 1-4 or unsp
–1 with HF and with CKD Stage 1-4 or unsp
–2 without HF and with CKD Stage 5 or ESRD
–3with HF and with CKD Stage 5 or ESRD

CONDITION SPECIFIC CODING
GUIDELINES
HTN HEART DISEASE W/CHF & CKD **REQUIRES THREE CODES ONE FROM HTN HEART DZ, CKD AND
CHF Use add'l code
–HCC **MAL W/HF W/CKD STAGE I-IV 404.01
–HCC **MAL W/CHF W/CKD ESRD 404.03
–HCC **BEN W/ HF W/CKD ST I-IV 404.11
–HCC **BEN W/ HF W/CKD ESRD 404.13
–HCC **UNSPEC I-IV 404.91
–HCC **UNSPEC W/HF W/CKD ESRD 404.93

CHRONIC KIDNEY DISEASE (CKD)

–HCC CHRONIC STAGE 1 GFR>90 585.1
–HCC MILD STAGE 2 GRF 60-89 585.2
–HCC MOD STAGE 3 GFR 30-59 585.3
–HCC SEVERE STAGE 4 GFR 15-29 585.4
–HCC NO DIALYSIS STATE 5 GFR <15 585.5
–HCC ESRD W/DIALYSIS 585.6
–HCC CKD UNSPEC, CRF 585.9
–HCC RENAL DIALYSIS STATUS V45.11

CONDITION SPECIFIC CODING
GUIDELINES
HTN LINKED HEART DISEASE w/CHF REQUIRES TWO CODES-ONE EACH
FROM HTN HEART DZ AND CHF

–HCC CHF UNSPECIFIED 428.0
–HCC LEFT HEART FAILURE 428.1
–HCC SYSTOLIC-UNSPEC 428.20
–HCC SYSTOLIC-ACUTE 428.21
–HCC SYSTOLIC-CHRONIC 428.22
–HCC DIASTOLIC-UNSPEC 428.30
–HCC DIASTOLIC-ACUTE 428.31
–HCC DIASTOLIC-CHRONIC 428.32
–HCC COMBINED-UNSPEC 428.40
–HCC COMBINED-ACUTE 428.41
–HCC COMBINED-CHRONIC 428.42
–HCC HEART FAILURE UNSPECIFIED 428.9

CONDITION SPECIFIC CODING
GUIDELINES
2.Diabetes Coding (HCC Categories 15, 16, 18, 19, 119):
•Documentation of complications or manifestations must be stated (‘due to’ or
‘secondary to’), or implied (Diabetic) and are reported with 4th digit

•If Type I or II is not mentioned code unspecified or type II DM. If controlled or
uncontrolled is not mentioned in the record, then code as controlled DM.

•Do not code 250.00 along with DM manifestations.

•Type I or II indicates type-Juvenile onset or Adult onset. (Type is not dictated by
use of insulin)

•If documentation indicates that the patient uses insulin routinely, append V58.67

•Sequence the 250 codes before the codes for the associated conditions

•Secondary diabetes coded to 249.XX

CONDITION SPECIFIC CODING
GUIDELINES
5TH Digit in Diabetes Coding

•0 indicates Type 2 or unspecified, not stated as controlled or uncontrolled

•1 indicates Type 1, not stated as controlled or uncontrolled

•2 indicates type 2 or unspecified, uncontrolled

•3 indicates type 1, uncontrolled

•Age is not a determining factor for type, though many develop Type 1 before
reaching puberty, thus the term ‘Juvenile’ diabetes.

CONDITION SPECIFIC CODING
GUIDELINES
Diabetes 249.XX

•Secondary Diabetes-Diabetes whose underlying cause is not genetics or
environmental conditions accounts for 1-5% of total diabetes cases. Presence of
another underlying condition is major differentiating factor.
•Coders must know:
–Manifestation
–Control
–Underlying etiology

CONDITION SPECIFIC CODING
GUIDELINES
Causes of Secondary Diabetes

–Chronic pancreatitis
–Hemochromatosis
–Pancreatic disease due to cancer, trauma or other endocrine diseases
–Carcinoid tumors of lung, intestine or stomach
–Adrenal and pituitary tumors
–Celiac disease and other autoimmune diseases
–Removal of pancreas
–Orchiectomy-removal of testes for cancer

Drugs and chemical agents:
–Diuretics and beta blockers
–Hormones
–Steroids
–Antipsychotics, lithium and antidepressants
–HIV drugs
–Seizure drugs
–Immunosuppressive drugs

CONDITION SPECIFIC CODING
GUIDELINES
Diabetes 250.XX
•Type 1 thought to be genetic, where the pancreas does not produce enough insulin. This usually
manifests at an early age, and usually requiresinsulin to manage, but not always
•Type 2 diabetes is caused by insulin resistanceinsulin is produced, but the body does not respond
properly. This usually (but not always) manifests in adulthood, may be managed with diet and
exercise, but may require oral meds or insulin. It may have a genetic component too.
4TH DIGIT MANIFESTATION
–0 NO COMPLICATION
–1 KETOACIDOSIS
–2 HYPEROSMOLALITY
–3 COMA
–4 RENAL MANIFESTATIONS
–5 OPTHALMOLOGICAL
–6 NEUROLOGICAL
–7 PERIPHERAL
–CIRCULATORY
–8 OTHER SPECIFIED
–9 UNSPECIFIED MANIFESTATIONS

CONDITION SPECIFIC CODING
GUIDELINES
Linking Words
•Linking words create relationship between diseases and manifestations
•Assures coders of a cause and effect between disease and manifestation, as we cannot assume
(except in hypertensive renal disease)
•Appropriate terms:
–Due to
–Secondary to
– Use of associative suffix ‘ic’ or ‘ive’ (diabetic ulcer or hypertensive heart disease)

For example:
Peripheral neuropathy due to DM
250.60 Diabetes with neurological manifestations
357.2 Polyneuropathy in DM
Diabetic Peripheral vascular disease
250.70 Diabetes with peripheral circulatory disorders
443.81 Peripheral Angiopathy In Diseases Classified Elsewhere
Dm with neuro manifestations – 250.60 only

CONDITION SPECIFIC CODING
GUIDELINES
3. Ulcers (HCC Categories 148, 149):
Ulcers and Wounds:
•These terms are not synonymous, although wounds can develop into ulcers
–Wounds are due to trauma or surgery-not risk adjusted
–Ulcers are caused by skin breakdown from pressure or other chronic conditions (nonpressure)
•Code ulcers to 707 series
•Code wounds to 870-879 series
Types:
– Non-pressure, or chronic
– Decubitus, or pressure, stages 1-5
Documentation is critical, as decubitus ulcers carry a higher risk adjustment
Stage 1 pressure ulcer of sacrum= 707.03 & 707.2
Diabetic calf ulcer= 250.80 & 707.12

CONDITION SPECIFIC CODING
GUIDELINES
4. Cardiac Disease Coding (HCC Categories 82, 83, 92):
–412 Old MI (myocardial infarction)-means > 8 weeks, currently presenting no
symptoms. Documentation may say ‘Old MI’, ‘h/o MI’, or‘s/p MI’
–410 Code series used for myocardial infarction <8 weeks in duration. The
initial or subsequent episode of care for selection of 5th digit by reviewing the
document carefully.
–411 Code series indicate other acute or subacute forms of ischemic heart
disease
–413 Code series used for various types of angina

CONDITION SPECIFIC CODING
GUIDELINES
5. Vascular Diseases (HCC Categories 104, 105):
•440 Atherosclerosis-a condition where there is reduced elasticity of the vessels and
narrowing of vessel lumen
•443 Peripheral Vascular Disease-a condition where the vessels in the arms or legs are
compromised causing blood flow issues. Common symptom intermittent claudication.
•451-453 Phlebitis and Thrombophlebitisconditions where vessels are irritated (‘-itis’)
by disease or infection, or clogged (thrombo-) and irritated by blood clots
Acute DVT: Initial episode of care, code 453.4x
Chronic DVT:
–Must be documented as chronic, code 453.5x
–Do not code DVT prophylaxis.

CONDITION SPECIFIC CODING
GUIDELINES
Atherosclerosis 440:
•Aortic atherosclerosis 440.0 May be noted from X-rays taken for other reasons-a
Chest X-ray may show aortic atherosclerosis. Documentation must detail the
finding of aortic atherosclerosis, (not just atherosclerosis) and the treatment plan
for this condition
•Atherosclerosis of extremities with Gangrene is coded to 440.24
•ASPVD with Ulceration without gangrene coded to 440.23 (addnl code for ulcer)

CONDITION SPECIFIC CODING
GUIDELINES
6. Cerebrovascular Accident (CVA) (HCC Categories 75, 95, 96):
•Use 434.91 for the initial episode of care for an acute cerebrovascular event –
may be documented as CVA or stroke- (usually within 24 hrs)
•Use V12.54 for a history of CVA/TIA with NO residual effects
•Once discharged, late effects are coded to 438 series

Late Effects
•The residual effect after the acute phase (24 hrs for CVA) of an illness or injury has passed
•No time limit on when a late effect code can be used
•Requires documentation that the residual effect was caused by the illness or injury
•Code first the condition, followed by the late effect
•‘Weakness’ is not appropriate documentation of hemiplegia or hemiparesis due to CVA

CONDITION SPECIFIC CODING
GUIDELINES
7.Respiratory Diseases (HCC Categories 108, 111, 112):
•COPD (Chronic obstructive pulmonary disease) is a lung condition whereby the lungs lose elasticity
and it is difficult to breathe, often associated with smoking
•Chronic bronchitis is inflammation of the airways that causes increased mucus to be produced.
Bronchitis is considered chronic if there is cough and excess mucus production most days for three
months in a year, two years in a row.
•Emphysema is a condition where the fine lacy architecture of the lung is disrupted, with less
surface area available to exchange oxygen
COPD & Asthma
•COPD (Chronic obstructive pulmonary disease) is a nonspecific ‘umbrella term’ for a host of
conditions, and is used when type of COPD is not specified
–491 Chronic bronchitis
–492 Emphysema
–493 Asthma

CONDITION SPECIFIC CODING
GUIDELINES
Documentation for Chronic Obstructive Bronchitis
•Code selection must be based upon terms as documented
•491.20 ‘Chronic bronchitis without exacerbation of COPD’
•491.21 ‘Chronic bronchitis with COPD exacerbation
–“Acute exacerbation of COPD”
–“Decompensated COPD”
•491.22 “COPD with acute bronchitis”
Coding for Emphysema
•492.0 Emphysematous bleb-usually found on imaging studies
•492.8 other emphysema-lung or pulmonary, centriacinar, centrilobular,
obstructive, panacinar, panlobular, unilateral, vesicular

CONDITION SPECIFIC CODING
GUIDELINES
Coding for Asthma
4th Digit defines Type
•493.0 Extrinsic, or allergic asthma, means that the cause is external to the body, such as from hay or other
airborne allergens. This causes the majority of childhood asthma
•493.1 intrinsic asthma-cause not precisely known, usually has onset later in life
•493.2 chronic obstructive asthma-occurs in the presence of COPD
•493.8 other forms of asthma
•493.81-exercise induced bronchospasm
•493.82-Cough variant asthma
•493.9-asthma unspecified
5th Digit defines current encounter
–0 UNSPECIFIED
–1 WITH STATUS ASTMATICUS (a life-threatening form of asthma in which progressively worsening
reactive airways are unresponsive to usual appropriate therapy that leads to pulmonary
insufficiency)
–2 WITH ACUTE EXACERBATION (a worsening or decompensation)

CONDITION SPECIFIC CODING
GUIDELINES
8.Major Depression (296) (HCC Category 55):
•Use of 296 category requires significant documentation that is not familiar to most primary care providers,
but is a common condition that risk adjusts even in remission. 311 is appropriate for situational depression
or depressed mood due to bereavement
Documentation for Major Depression
•Not directly due to a substance or bereavement
•Symptoms present for 2 weeks or more and cause clinically significant distress or impairment
•*At least one of the following:
–Depressed mood most of the day, nearly every day
–Diminished interest in activities
•*At least 4 of the following:
–Weight/appetite loss or gain (>5% in a month)
–Insomnia or hypersomnia
–Agitation or retardation observed by others
–Feelings of worthlessness or guilt
–Diminished ability to think or concentrate
–Recurrent thoughts of death, suicidal ideation or attempt
*PHQ-9 Score of 10, or some other standardized tool (Beck) may be used in lieu of above. This documentation
must be noted with the provider’s credentials and date of service in order to be considered.

CONDITION SPECIFIC CODING
GUIDELINES
9.Malnutrition (263) (HCC Category 21):
•Supportive documentation:
–Albumin <3.4
–Unintentional weight loss >10% over 6 months
–Unintentional weight loss>5% over 3 months
–BMI <18.5
–Poor nutrition or loss of appetite
–Wasted appearance, or muscle wasting
10.Rheumatoid Arthritis (RA):
–Chronic, systemic inflammatory disorder
•Attacks flexible (synovial) joints
•Code 714.0
•Use additional code to identify manifestation when documented

CONDITION SPECIFIC CODING
GUIDELINES
11.Neoplasms(HCC Category 10):
•Current treatment codes to active cancer code, even if there is no evidence of disease.
Documentation must state “Breast cancer on Arimidex…”
•If there is no evidence of disease and the patient is not being treated, the V code is reported.
•If documentation does not state that there is active disease or treatment, the V code is used
•Patients with cancer that is not being treated are coded to active cancer
Metastasis of Cancer
•Metastatic cancer (spread of cancer to another organ system) is the highest risk adjusted
diagnosis, and documentation is critical!
•If there is metastasis, documentation must state the primary cancer and the location of the
metastasis (mets). “Brain cancer with mets to lung’. Code primary cancer first, then mets
•If the primary cancer has been removed and treatment is directed at the mets, code the mets
first, followed by the V code for the primary cancer. Documentation must state “history of
breast cancer with mets to lung”

CONDITION SPECIFIC CODING
GUIDELINES
Codes that Providers Often Miss:
•Artificial openings
•Amputations
•Aortic aneurysm
•Aortic atherosclerosis
•If these are not documented yearly, the codes are not considered in the payment
for the following year!
ICD9 Codes Only
•Some physician records contain only ICD-9-CM codes without the code’s
description. For risk adjustment coding, there must be documentation of the
condition elsewhere on that DOS. If the record does not document the condition
(other than listing only the ICD9 code), do not code the condition.

CRITICAL CONDITIONS CODING
GUIDELINES
I.Cancer
•If documentation is not clear regarding whether a neoplasm is benign or malignant, use the alphabetic
index to find the morphological term used to describe the behavior of the neoplasm. For example, the term
leiomyosarcoma is indexed to malignant neoplasms in the ICD-9 code book. On the other hand,
lipoblastoma is indexed to benign neoplasms in the ICD-9 coding manual.
Current Cancer vs. History
•Coders must use the entire document for each DOS to determine whether the malignancy should be coded
history or current. Documentation must show clear presence of current disease to code current
malignancy. There are some instances in which the malignancy should be coded as current.
1. Document indicates either the patient or physician chose not to treat the cancer (e.g. choosing not to
continue treatment of a terminal disease) OR
2. Document shows evidence of current/ongoing treatment of the disease:
–Chemotherapy (e.g. antineoplastic medications)
–Radiation therapy (e.g. including radioactive seed implantation to provide continuous ambulatory radiation)
–Suppressive therapy (e.g. hormonal therapy, like Lupron for advanced prostate cancer)
–Surgical treatment (e.g. a preoperative examination prior to colectomy) OR
3. Documentation shows that current treatment is being temporarily stopped for the following reasons:
–To determine an appropriate or alternate treatment plan for the patient’s cancer
–To allow the patient to rest clinically from the effects of treatment (chemo/radiation)
–To transfer of care where treatment is to be continued by another provider

CRITICAL CONDITIONS CODING
GUIDELINES
Primary vs. Secondary
•Metastatic from = Primary Example: Malignancy of the colon metastatic from prostate.
–Colon cancer is secondary
–Prostate cancer is primary
•Metastatic to = Secondary Example: Breast cancer with metastasis to the mediastinal lymph nodes.
–Breast cancer is primary
–Mediastinal lymph nodes cancer is secondary.
•If the documentation just says “metastatic” assign the primary malignancy along with an additional code
for secondary of unspecified site 199.1. (Faye Brown’s ICD-9-CM Coding Handbook 2011, pg. 381)
•If a malignancy is not specified as primary or secondary, for coding purposes we assume its primary unless
the site is one of the following:
–Bone, Brain, Diaphragm, Heart, Liver (see below)
–Lymph nodes, Mediastinum, Meninges, Peritoneum, Pleura, Retroperitoneum, Spinal cord
•Malignant neoplasms of these sites are classified as secondary when not otherwise specified, except for
neoplasm of the liver. *The liver basically has 3 possible morphological designations:
–Liver, primary – code 155.0
–Liver, secondary – code 198.89
–Liver, not specified as primary or secondary – code 155.2

CRITICAL CONDITIONS CODING
GUIDELINES
In Remission
•Lymphoma patients who are “in remission” are still considered to have lymphoma
and should be assigned the appropriate code from categories 200-202 (AHA Coding
Clinic for ICD-9-CM, 1992, 2Q, p3). Do not to confuse lymph node metastasis with
lymphoma. Do not assign a history code for lymphoma stated as in remission.
•For use with 203-208 category of ICD-9 codes
–0 Without mention of having achieved remission
–1 In remission
–2 In relapse

CRITICAL CONDITIONS CODING
GUIDELINES
In-Situ
•A neoplasm described as in-situ (230-234) has not metastasized or spread to any other area of the body.
ICD-9 offers specific guidance via the index for coding purposes. A neoplasm described as both in-situ and
secondary, represents a conflict in the medical documentation. Look carefully through the history
section of the medical record if past medical treatment (surgical/radiation/chemotherapy) or other
indication exists to support the behavior of the neoplasm. Use sound coding judgment and context to
determine the appropriate behavior based on the treatment(s) documented and MEAT to support the
chosen code.
•Carcinoma in situ: Cancer that has stayed in the place where it began and has not spread to neighboring
tissues (for example, squamous cell carcinoma in situ). The term is synonymous with high-grade dysplasia
in most organs. The risk of transforming into cancer is high.
Example 1
Medical record
documentation
The record states the patient had a radical mastectomy for right breast cancer 8
months ago, followed by chemotherapy and radiation that was completed 2
months ago, followed by initiation of Tamoxifen for adjuvant therapy for current
breast cancer. The record does not state the specific purpose of Tamoxifen
therapy. Record states the patient is tolerating the Tamoxifen well.
Coding advice In this scenario, breast cancer is coded as current. The record states Tamoxifen
is adjuvant therapy for current breast cancer, does not describe breast cancer as
historical, and does not state the patient is cancer free or without evidence of
disease.

CRITICAL CONDITIONS CODING
GUIDELINES
Example 2
Chief Complaint Prostate cancer
History of Present Illness Seen today for metastatic prostate cancer. Prior records reviewed, has been
maintained on monthly Lupron injections for the past year with last PSA 3 months
ago down to 1.9. Currently no pain with urination, no gross hematuria, no urinary
incontinence. Takes Flomax daily which helps improve overall urinary stream. No
bone pain or weight loss.
Review of Systems As above. All other systems negative.
Physical Exam BP 118/70, P 78, R 18, T 98.2. Well nourished, well developed male in no acute
distress. Alert & oriented. Lungs clear. Heart RRR, S1 & S2, no gallops, rubs or
murmurs. Abdomen soft and non-tender with no evidence of mass or organomegaly.
Extremities: no cyanosis, clubbing or edema. Genital &rectal exam deferred today.
No lymphadenopathy noted.
Assessment Metastatic prostate cancer
Plan Discussed with patient a three-month Trelstar injection today – all questions
answered. Trelstar LA 11.25 mixed in standard fashion and injected deep IM to R hip.
Tolerated well. Does not require refill of Flomax today. PSA in 10 weeks with f/u
office in 12 weeks.
ICD-9-CM codes 185, 199.1

CRITICAL CONDITIONS CODING
GUIDELINES
II.Acute/Old MI
•Myocardial infarction is coded as acute (410.XX) for the first 8 weeks following onset. In category 410 the
fourth digit indicates location of the infarct and the fifth digit indicates episode of care. Note that a fifth
digit of 1 should be used during the initial episode of care, which likely will occur in an inpatient or ER
setting.
•After 8 weeks have passed, myocardial infarction is considered Old MI (412). If unable to determine age
of the infarct, use 412. Many different terms are used to describe past heart attacks, some of the most
common terms are listed below. Please note you will likely find this information in the past medical
history (PMH).
PMI – perioperative myocardial
infarction
Health previous myocardial
infarction
AMI -acute myocardial infarction
Old Septal MI Healed or Old cardiac thrombus Anterior wall MI
Inferoposterior MI Prior small inferior wall
myocardial infarction
NSTEMI / STEMI (non ST-
elevation / ST elevation
myocardial infarction)

CRITICAL CONDITIONS CODING
GUIDELINES
Example 1
After emergency room evaluation, a patient was admitted to Memorial Hospital with a diagnosis of
acute
anterior wall myocardial infarction. There was no history of previous infarction or previous care for this
episode. During the hospital stay, the patient experienced a second acute anterolateral infarction.
ICD-9-CM codes 410.11, 410.01
Example 2
Patient presents to cardiologist’s office for post-hospital evaluation. Record documents 76 y/o male
admitted
to XYZ Medical Center four weeks ago with c/o chest pain. Was noted to have acute lateral wall
myocardial
infarction and had placement of stent mid circumflex. Recommendation is to continue cardiac rehab.
ICD-9-CM code 410.52
Example 3
Inferior MI six months ago – 412

CRITICAL CONDITIONS CODING
GUIDELINES
III.Stroke/Acute Cerebrovascular Disease (Codes 430-437)
•Codes from 430-437 should be used ONLY during the initial episode of care. After this, use a “history”
code or late effects code.
•During the initial episode of care, an acute CVA that results in current neurologic deficits is coded from the
430-434.9 series, with additional codes assigned to represent the specific neurologic deficit. For example,
an inpatient admission for acute CVA with a current associated right Hemiplegia is coded 434.91 for the
acute CVA and 342.90 for the associated right Hemiplegia
•Late effects codes should be used anytime after the initial episode of care when documentation states a
condition was caused by a past stroke. Evidence of the residual condition should be included in
documentation on that DOS.
•In some cases, a patient is admitted with an acute CVA with current associated deficits while at the same
time having current neurologic deficits that are the result of a past CVA. In this case, codes are assigned
from both categories 430-437 and 438.
•V12.54 is assigned only when there is a history of CVA with no residual deficits.
•According to Coding Clinic, 2005 Q1, the term "weakness" secondary to old CVA is not to be coded as
hemiparesis/Hemiplegia. Weakness is coded as 728.87, muscle weakness, and if noted to be secondary to
old CVA, then 438.89, other late effects of cerebrovascular disease should also be coded.

CRITICAL CONDITIONS CODING
GUIDELINES
Example 1
Final Diagnostic Statement Admit for acute CVA in patient with old right
hemiparesis from past stroke
ICD-9-CM code(s) 434.91, 438.20
Example 2
Final Diagnostic Statement Embolic stroke with dysphasia
Plan Admit and request stat neurology consult.
ICD-9-CM code(s) 434.11, 784.59
Example 3
Final Diagnostic Statement Receiving home health speech therapy services
related to oropharyngeal dysphagia caused by
cerebrovascular accident one month ago.
ICD-9-CM code(s) 438.82, 787.22

CRITICAL CONDITIONS CODING
GUIDELINES
IV.Aneurysm
•If an aneurysm has been repaired, it no longer exists and should not be
coded. History of aneurysm should be coded V12.59.

•As always, code assignment is dependent on the documentation in the
individual medical record. Best practice includes documentation that is
clear, concise and specific, fully describing the aortic aneurysm or
dissection, including all of the following:
–The specific location along the aorta (i.e., abdominal, thoracic,
thoracoabdominal, etc.)
–The current status (i.e., stable, enlarging, specific measurements, etc.)
–The current treatment plan (i.e., ultrasound in six months to monitor,
continue to monitor with repeat CT scan in one year, referral to
vascular surgeon for evaluation, etc.)

CRITICAL CONDITIONS CODING
GUIDELINES
1.Final Diagnostic Statement Aneurysm of the ascending aorta, currently measures 4.0 cm by
CT.
Plan Continue observation and recheck at annual exam next year.
ICD-9-CM code(s) 441.2
Comments The ascending aorta is part of the thoracic aorta and classifies to
code 441.2.
2.Final Diagnostic Statement Asymptomatic thoracoabdominal aortic aneurysm: stable.
Thoracoabdominal aorta dilation 3.4 cm by diagnostic CT scan 2
yrs. ago, time for recheck.
Plan Scheduled for CT scan of the chest and abdomen at Medical Center
next Tuesday at 8:00 AM.
ICD-9-CM code(s) 441.7

CRITICAL CONDITIONS CODING
GUIDELINES
V.DVT/PE
•Acute DVT (453.4X) or acute pulmonary embolism (415.19) is a newly developed
clot that requires the initiation of anticoagulant therapy. DVT and PE can only be
coded during initial episode of care.
•Chronic DVT (453.5X) can only be coded if the provider documents that the
condition is chronic.
•Do not assume that patients on anticoagulation meds have chronic DVT.
Anticoagulation meds could be for prevention of recurrence, which would be
coded history of DVT (V12.51).
•Do not code prophylaxis for DVT as current DVT. (Prophylaxis is to help prevent
DVT.)
•In a patient with chronic DVT or PE be cautious that the condition is indicated as
current and not listed as past medical history.
•When a patient with DVT or PE requires long term anticoagulation it is important
to document this along with the management plan.

CRITICAL CONDITIONS CODING
GUIDELINES
Example 1
Patient presents with chief complaint of swelling in
legs & calf tenderness for past two days. Objective
data includes asymmetric swelling with the right leg
measuring close to 42 cm, the left measuring at 37
cm. Positive Homan’s sign. Stat venous Doppler
shows DVT in the right posterior tibial. Negative left
leg venous Doppler. Started on Coumadin 5 mg daily
and Lovenox 80 mg subQ bid until INR therapeutic
between 2 & 3.
ICD-9-CM code: 453.42
Example 2
Patient presents for anticoagulant follow-up for
recurrent DVT.
Physical exam unremarkable. INR 2.8 (therapeutic).
Plan: Continue current Coumadin dose – 5mg M-W-
F, 2.5 mg others. Written instructions reviewed with
& given to patient. Recheck 1 month.
ICD-9-CM code: V58.61

CRITICAL CONDITIONS CODING
GUIDELINES
VI.Fractures
Fractures which map to HCCs are usually coded from IP or ER records. Below are some examples
for which an acute fracture code (pathological or traumatic) should be used:
•Surgical intervention and/or the hospital stay during which surgical intervention was
performed.
•Initial stabilization, such as that done in an emergency room.
•The first visit for assumption of (taking over) care from one doctor to another.
•For example: if the surgical/stabilization care only was done by one provider (circumstances
where global package with modifier 54 would be charged) and the remainder of the care is
assumed by a different provider (circumstances where global package with modifier 55
would be charged), both of these would be reported with the acute fracture code.”
•Traumatic and pathologic fractures are coded using the aftercare codes (subcategories
V54.17 and V54.27) for encounters after the patient has completed active treatment as
described above and is receiving routine care for the fracture during the healing or recovery
phase. Examples of fracture aftercare include medication adjustment and follow-up visits.
•When the medical record does not specify whether the fracture is traumatic or pathologic,
the default is traumatic.

CRITICAL CONDITIONS CODING
GUIDELINES
Example 1
80 year old female presents with complaints of low
back pain x 1 week. She has a history of
osteoporosis. Patient states the pain is mild to
moderate, but seems to be getting better. Lumbar X-
ray in the office today shows compression fracture at
L1-L2.
Impression Lumbar compression fracture
Plan Advised to take OTC ibuprofen
three tablets every 4-6 hours for
low back pain. Return to the
office for re-eval in two weeks if
symptoms do not continue to
improve.
ICD-9-CM code 805.4
Example 2
Patient comes in today for routine follow-up. Voices
no new complaints. Continues to wear back brace for
chronic spinal compression fractures diagnosed at
last visit two months ago.
Impression Chronic spinal compression
fractures
Plan Continue back brace and pain
meds. Refilled Fosamax.
ICD-9-CM code 733.13

CRITICAL CONDITIONS CODING
GUIDELINES
VII. Sick Sinus Syndrome (SSS) S
Sick sinus syndrome classifies to code 427.81. This code also includes:
–Sinoatrial node dysfunction
–Severe sinus bradycardia
–Chronic sinus bradycardia
–Persistent sinus bradycardia
–Tachycardia-bradycardia syndrome
•When a patient has a previously placed pacemaker and it is interrogated during a
hospitalization or in the office setting, code V53.31 is assigned (Fitting and
adjustment of other device, Cardiac device, cardiac pacemaker).
•• A code is not assigned for sick sinus syndrome when it is being controlled by the
pacemaker and no problems are detected during the check. Interrogation is a
routine check, which is done via computer to assess pacemaker function. The
pacemaker is routinely evaluated to ensure the device is programmed accurately
as well as to assess battery and lead function. Pacemaker settings may be
reprogrammed, if required.
•Thus, sick sinus syndrome (SSS) can be coded as a current condition only when
documented as a continuing and ongoing problem; and, if a pacemaker is present,
the condition is not controlled by the pacemaker.

CRITICAL CONDITIONS CODING
GUIDELINES
Example:
Reason for Visit Follow-up for heart disease
History of Present Illness Continues to have shortness of breath, dizziness, swelling in
LE, some difficulty walking – uses a cane for aid with ambulation.
Past Medical History CAD, hyperlipidemia, HTN, IDDM, CHF, SSS, stroke/TIA, DJD,
depression
Medications Neurontin, Lipitor, furosemide, Humulin insulin, ASA, Plavix, potassium,
atenolol, Zoloft, OTC Tylenol
Physical Exam BP 118/88. P 52 and regular. No JVD; normal respiratory effort;
diminished breath sounds bilat; Heart regular but slow, PMI not displaced, no
thrills, lifts, or palpable S3 or S4, 1+ pitting edema of the ankles, normal pedal
pulses with good capillary refill. Recent carotid dopplers look good.
Assessment 1) HTN controlled 2) IDDM 3) CHF – stable 4) persistent sinus bradycardia
Plan Take an extra Lasix daily if needed for swelling in LE. Refer to cardiology for eval
of persistent sinus bradycardia, possible pacemaker placement.
ICD-9-CM codes 401.9, 250.00, 428.0, 427.81, 272.4, 414.01, V58.67, 311

CRITICAL CONDITIONS CODING
GUIDELINES
VIII.Artificial openings
• An artificial opening is a surgically created opening from the outside surface of the
body into an internal body structure. (For example, a colostomy is a surgically
created artificial opening from the abdominal wall into the colon; a tracheostomy
is a surgically created artificial opening from the outside surface of the neck into
the trachea).
• Artificial opening status classifies to category V44.
• Attention to artificial openings classifies to category V55. The “attention to”
codes are not assigned for the date of the initial placement or surgical creation of
an artificial opening. On the date an artificial opening is surgically created, the
services are reported using procedure codes and the ICD-9-CM code(s) that
represent the condition for which the artificial opening was surgically created. The
“attention to” codes are used for subsequent visits that occur after the initial
surgery in which the artificial opening was created.
• Artificial openings can be coded when the record clearly shows the artificial
opening, complication, fitting of, attention to, etc. is still present and current.

CRITICAL CONDITIONS CODING
GUIDELINES
•suprapubic cystostomy - V44.59
–596.81 Infection of cystostomy
–596.82 Mechanical complication of cystostomy
–596.83 Other complication of cystostomy

•Ileal conduit status: V44.6 (Status of other artificial opening of urinary tract)
–Attention to ileal conduit: V55.6 (Attention to other artificial opening of
urinary tract)
–Complication of an ileal conduit: 997.5 (Urinary complications).
•G-tube status: V44.1 (Assigned to document the presence of a G-tube)
– Attention to a G-tube: V55.1 (Examples: simple irrigation or replacement
of a G-tube)
– Complications of gastrostomy tubes: Subcategory 536.4
•J-tube status: V44.4, Status of other artificial opening of gastrointestinal tract.
– Attention to a J-tube: V55.4, Attention to other artificial openings of
digestive tract.

CRITICAL CONDITIONS CODING
GUIDELINES
IX.Atrial fibrillation
•The documentation shows atrial fibrillation is a current condition, responsible for
current signs or symptoms that require further evaluation, management or
treatment.
•Atrial fibrillation is listed in the final diagnostic statement and there is no
contradictory information documented elsewhere in the record that indicates
atrial fibrillation is not current.
•The AHA Coding Clinic guideline for Atrial fibrillation on medication maintenance,
Third Quarter 1995, Page 8, advises chronic atrial fibrillation controlled on
maintenance medication can be coded as a current condition if the physician
documents the condition in the medical record and includes it in the final
diagnostic statement.

CRITICAL CONDITIONS CODING
GUIDELINES
Example 1
•Subjective 73 year old female returns today for recheck regarding her long-term
anticoagulation therapy secondary to her atrial fibrillation. Currently she is taking
3.5 mg of Coumadin daily. Her protime today is 27.3, INR 2.7. Denies any chest
pain, palpitations, and shortness of breath or dizziness. Daughter in attendance
and reports her mother continues to be forgetful but she is assisting her with her
meds.
•Objective BP 120/82. Pulse 57. Respirations 16. Weight 150. Lungs clear to
auscultation with no wheezes, rales or rhonchi. Heart regular rate and rhythm with
no rubs, murmurs or gallops. Exam otherwise unremarkable.
•Assessment 1. Atrial fibrillation 2. Long term anticoagulant therapy 3. Early
dementia
•Plan Continue current dose of Coumadin at 3.5 mg daily. Return to clinic in one
month for recheck.
•ICD-9-CM code(s): 427.31, V58.61, 294.20
•Comments Atrial fibrillation is documented as a current condition on long-term
anticoagulant therapy.

CRITICAL CONDITIONS CODING
GUIDELINES
X.Cardiomyopathy:
•A simple diagnostic statement of “cardiomyopathy” with no further description or
specification classifies to code 425.4, other primary cardiomyopathies. Code 425.4 includes
cardiomyopathy described as congestive, constrictive, familial, idiopathic, obstructive,
restrictive, and also includes cardiovascular collagenosis.
•Congestive cardiomyopathy is also known as dilated cardiomyopathy
•Hypertrophic cardiomyopathy can be obstructive or non-obstructive.
–425.11 Hypertrophic obstructive cardiomyopathy
–425.18 other hypertrophic cardiomyopathy
•Use caution when coding cardiomyopathy from acronyms (CM, HCM, HOCM, etc.) A code
should not be assigned unless the meaning of the acronym is clear based on overall review of
the entire record.
Example 1
Final Diagnostic Statement Ischemic cardiomyopathy
ICD-9-CM code(s) 414.8
Example 2
Final Diagnostic Statement Hypertensive cardiomyopathy
ICD-9-CM code(s) 402.90, 425.8

CRITICAL CONDITIONS CODING
GUIDELINES
XI.Seizure Disorder/Epilepsy
Seizure - An abnormal electrical discharge in the brain caused by clearly identifiable external factors that may
be resolved or reversed (for example, injury, high fever, substance abuse, metabolic disorders).
Epilepsy aka seizure disorder - A chronic brain disorder characterized by recurrent (two or more) seizures on
more than one occasion that are not provoked by a clearly identifiable external factor.
–Intractable Epilepsy – Epilepsy that does not respond to treatment.
–Status epilepticus – A potentially life-threatening state in which a person experiences an abnormally
prolonged seizure (any seizure lasting longer than 5 minutes) or does not fully regain consciousness
between seizures. This condition represents a medical emergency.
When a medical record documents a single seizure, code 780.39 is assigned. Category 345 represents Epilepsy
and recurrent seizures.
As always, code assignment is dependent on the specific documentation in each individual medical record.
Documentation should be clear and concise, fully describing
a) The specific type of seizure(s), convulsion(s), or epilepsy;
b) The current status of the condition; and
c) Any ongoing treatment.

CRITICAL CONDITIONS CODING
GUIDELINES
Example 1
Final Diagnostic Statement: Grand mal seizures – on Dilantin
Plan: Check Dilantin level
ICD-9-CM code: 345.10
Example 2
Chief Complaint: Presents for follow-up of partial complex seizures. Reports no
seizure activity for last 60 months. Current seizure medications include
carbamazepine 200 mg 1 ½ tablets bid. Medication compliance has been good.
Past Medical History: Patient has had seizure disorder since 1995; last seizure 2005;
partial seizures are a result of ruptured aneurysm.
Review of Systems: All systems reviewed and negative.
Physical Exam: All within normal limits.
Assessment: Partial complex seizures
Plan: Refill carbamazepine. Return in 3 months.
ICD-9-CM code: 345.40

CRITICAL CONDITIONS CODING
GUIDELINES
XII.Pressure ulcer (aka pressure sore, bed sore, Decubitus ulcers)
•Two codes are required to report pressure ulcers.
– 1. First, a code is assigned from the 707.00-707.09 series to report the site.
– 2. An additional, second-listed code is assigned from the 707.20 – 707.25 series to report the stage.
•Codes in subcategory 707.2X are used for staging of pressure ulcers only and are not used with any other
type of ulcer.
•Code 707.25 for unstageable pressure ulcer should not be confused with code 707.20 for unspecified
stage of pressure ulcer. Code 707.25 is assigned when the stage of pressure ulcer cannot be determined
(for example, the ulcer is covered by eschar, a tissue graft or a dressing) or for pressure ulcers
documented as deep tissue injury but not documented as due to trauma.
•Bilateral pressure ulcers with the same stage and site are coded with only one code for the site and one
code for the stage.
•Bilateral pressure ulcers at the same site but with different stages are coded with one code for the site
and the appropriate codes for each stage.
•Multiple pressure ulcers at different sites and stages are coded with the appropriate codes for each
different site and each different stage.
•If the documentation states a pressure ulcer is completely healed, no code is assigned.
•If the documentation states a pressure ulcer is healing, appropriate codes are assigned based on the
documentation in the record.
•If a patient is admitted with a pressure ulcer in one stage that progresses to a higher stage, the code for
the highest stage reported is assigned

CRITICAL CONDITIONS CODING
GUIDELINES
Example 1
Final Diagnostic Statement: Gangrenous pressure ulcer right heel
ICD-9-CM code(s) : 707.07, 785.4, 707.20
Example 2
Final Diagnostic Statement : Pressure ulcer coccyx, not staged since covered
with dressing
ICD-9-CM code(s): 707.03, 707.25
Example 3
Final Diagnostic Statement: Stage I foot ulcer
ICD-9-CM code(s): 707.15

CRITICAL CONDITIONS CODING
GUIDELINES
XIII.Peripheral Neuropathy
•Peripheral neuropathy that is not further specified or described is coded 356.9.
•Peripheral neuropathy of an arm/upper extremity (unilateral) classifies to code
354.9. Peripheral neuropathy of a leg/lower extremity (unilateral) classifies to
code 355.8.
•Peripheral neuropathy of BOTH legs/lower extremities (bilateral) or BOTH
arms/upper extremities (bilateral) represents a polyneuropathy and is coded
356.9. (AHA Coding Clinic guideline for Peripheral neuropathy, First Quarter 2013,
Pages 3-4).
•Polyneuropathy of the lower extremities classifies to code 356.9.
• A diagnostic statement of simply “Neuropathy” with no further specification or
description classifies to code 355.9.
•Idiopathic peripheral autonomic neuropathy (assigned to category 337) should
not be confused with idiopathic peripheral neuropathy (assigned to category
356).
• Code 356.2 represents hereditary sensory neuropathy. Code 356.2 is assigned
only when the record describes sensory neuropathy as hereditary.

CRITICAL CONDITIONS CODING
GUIDELINES
Example 1
Final Diagnostic Statement Peripheral neuropathy related to vitamin B deficiency
ICD-9-CM code(s) 266.9, 357.4
Example 2
Final Diagnostic Statement Hereditary neuropathy
ICD-9-CM code(s) 356.9
Example 3
Final Diagnostic Statement Hereditary sensory neuropathy
ICD-9-CM code(s) 356.2
Example 4
Final Diagnostic Statement Peripheral neuropathy due to chemotherapy
ICD-9CM code(s) 357.6
Example 5
Final Diagnostic Statement Peripheral neuropathy left leg
ICD-9-CM code(s) 355.8

CRITICAL CONDITIONS CODING
GUIDELINES
XIV.HYPOXIA
•Hypoxia and hypoxemia that are not further specified classify to code 799.02
• Sleep-related hypoxia classifies to code 327.24. Nocturnal hypoxia (hypoxemia) is
hypoxia (hypoxemia) that occurs during sleep. Nocturnal hypoxia/hypoxemia also
classifies to code 327.24.
• When hypoxia is documented with COPD, it is appropriate to code both
conditions.
•A patient may have oxygen saturation below 90% on room air in record, but code
799.02 cannot be assigned unless the provider documents a diagnosis of hypoxia.
Example 1
Vitals: O2 saturation 89% on 4 LPM
Assessment: Hypoxia on continuous home oxygen therapy
ICD-9 codes: 799.02, V46.2

CRITICAL CONDITIONS CODING
GUIDELINES
XV.Diabetes and Gangrene
•If a record documents both gangrene and diabetes, assume the gangrene is a
consequence of diabetic peripheral circulatory disorder if no other cause is
established by the documentation (especially if the gangrene is of the lower
extremity). In this scenario, codes 250.7X and 785.4 would be assigned. If the
record documents a history of a traumatic wound that led to gangrene, this would
be coded as a complicated open wound, with the addition of codes 785.4 for
gangrene and 250.0X for diabetes.
XVI.Diabetes and Osteomyelitis
•ICD-9-CM assumes a cause-and-effect relationship between diabetes and
osteomyelitis when both conditions are documented and there is no
documentation of any other cause unless the provider specifically states the two
are not related. Diabetes not further specified that is documented with
osteomyelitis, with no other specified cause, is coded 250.80, 731.8, and 730.0X.

CMS Documentation Signature
Requirement
For purposes of risk adjustment, the provider of service for face-to-face encounters is appropriately identified
on the medical records via their signature and provider specialty credentials. Examples of acceptable types
of physician signature are:
–Handwritten signature or initials with credential
–Electronic signature with authentication by the respective provider
–MD, DO, NP, PA-C, PT, OT, MSW, CRNA, CNS, etc. must be documented so that the proper credentials of the treating
provider are clearly known. (Note: “Dr.” is not an accepted credential.)
Acceptable electronic signatures include:
•Electronically signed by,
•Authorized by,
•Document generated by,
•Sealed by,
• Closed by,
•Printed and signed,
•Signature on file (with printed name),
•Attested by,
•Approved by,
•Completed by,
•Finalized by,
•Validated by, etc. followed by the practitioner’s name and credentials.

Valid Provider signature
•P.A
•RPA
•N.P
•ARNP
•FNP
•CRNP
•MD
•DM
•DO
•DPM
•PT
•OT
•LCSW
•LMSW
•DNP
•CNP
•APRN
•APN
•ANPC (Adult Nurse Practioner certified)

Documentation Tips
•Commonly used by providers to mean the condition is part of the patient’s history,
‘h/o’ or ‘s/p’ is indicative to coders of a past condition and cannot be coded as
active disease.
•Remember to use linking terms like ‘due to’ or ‘secondary to’ to describe
relationships between diseases and manifestations
•Documentation must indicate a treatment plan for each diagnosis, such as ‘refer
to cardiologist’, or ‘observation for exacerbation or worsening’ and an assessment,
such as ‘stable’, ‘worsening’, ‘not responding to treatment’

Clinical Specificity in
Documentation
•Clinical specificity involves having a diagnosis fully documented in the source
medical record instead of routinely defaulting to a general term for the diagnosis.
It is important to understand medical terminology in order to identify terms in the
medical record that may be a more specific description of a general term.
•Communication with the physician is key to improving documentation skills that
allow for more specific coding. The following examples are guidelines and specific
conditions selected from various chapters of ICD-9-CM (e.g., Circulatory,
Respiratory, Neoplasm, etc.) that are representative of documentation and coding
decisions that impact HCCs.
•The first three examples involve situations in which a physician may use the most
common code for all forms of a disease and conditions. Remember, this practice
has had no impact in the past on physician reimbursement. With the Risk
Adjustment models, physicians must be careful to document the correct forms
and manifestations of diseases and conditions.

Clinical Specificity in
Documentation
Example 1:
Anemia (285.9) is the most commonly coded form of anemia in physician offices. However, there are
many types of anemia. Some are in the models and some are not. If the term “neutropenia” is used
to describe the anemia, it must be coded to the more specific diagnosis code 288.0
(agranulocytosis), which groups to HCC 45. “Refractory” anemia is coded 238.7 (HCC 44). It is
important that physicians document these types of anemia accurately.
Example 2:
Pneumonia (486) unspecified is not in the model. If the organism responsible for the pneumonia (HCC
111-112) is known or if the physician documents that the patient aspirated prior to developing
pneumonia (507.0 HCC 111), the more specific code should be reported
Example 3:
Mental disorders in the HCC models require particular attention to specific wording in documentation
and coding. Episodic mood disorders (296.XX, HCC 55) are mental diseases that include mood
disturbances such as major depression (296.2X-296.3X). Physicians are encouraged to carefully
document the characteristics of the mood disturbance (e.g., mania, depression, single episode,
recurrent episode, circular) and use specific mental disorder terminology in the final diagnosis. The
coder is cautioned to exactly code only the narrative provided by the physician in the final diagnosis
and not make any further assumptions based on the patient work-up. For example, in coding
depression, careful use of the ICD-9-CM index directs the coder to the correct type documented. If
the physician does not document specific descriptor terms such as “major” or “recurrent”, then
code 311 (depression, not otherwise specified, not in the model) is used.

Clinical Specificity in
Documentation
•Use of “history of.” In ICD-9-CM, “history of” means the patient no longer has the condition and the
diagnosis often indexes to a V code not in the HCC models. A physician can make errors in one of two ways
with respect to these codes. One error is to code a past condition as active. The opposite error is to code
as “history of” a condition when that condition is still active. Both of these errors can impact risk
adjustment.
Example: 1
The diagnosis statement “history of hip fracture” is not coded as a current hip fracture (820.8, HCC 158),
but with a V code for orthopedic aftercare (V54.XX) or history of injury (V15.5), if appropriate. Neither
“history of” code is in the HCC models. If a patient has a current acute condition, then the “history of”
wording should not be used to describe the recent occurrence.

Example: 2
The physician may actually intend to communicate that a condition is ongoing, but note the “history of” a
condition. An example of this is “history of Hepatitis C” (V12.09 personal history of other infectious
disease). Hepatitis C generally presents as a chronic condition (070.54, HCC 27) that is rarely fully
eradicated. While assigning V12.09 is not necessarily an example of incorrect coding, it may indicate that
the physician office is not coding correctly. Again, communication and clear documentation are essential
to make the appropriate determination.

Clinical Specificity in
Documentation
Correct use of associated terms:
•Some conditions are described by more than one term depending on the clinical
presentation and medical terminology practices of the physician. Coders must be
careful not to assign a diagnosis to conditions that are not specified by the
physician and cannot be validated by the medical record.

DOCUMENTATION CONSIDERATIONS
Documentation Guidelines
•Reported diagnoses must be supported with medical record documentation.
•Medical records and codes are subject to CMS validation.
•Characteristics of acceptable documentation include:
–Clear.
–Concise.
–Consistent.
–Complete.
–Legible.
Physician Documentation and Communication Tips
•Document and report co-existing diagnoses.
•Communicate issues regarding inadequate documentation.
•Adhere to proper methods for appending (late entries) or correcting inaccurate data entries.
–Lab/Radiology results.
–Strike through, initial, and date. Do not obliterate.
•Use only standard abbreviations.
•Identify patient and date on each page of the record.
SOAP Notes
•SOAP note format assists both the physician and record reviewer/coder in identifying key
•documentation elements. SOAP stands for:
–Subjective: How the patients describe their problem or illness.
–Objective: Data obtained from examinations, lab results, vital signs, etc.
–Assessment: Listing of the patient’s current condition and status of all chronic conditions. How the objective data
relate to the patient’s acute problem.
–Plan: Next steps in diagnosing problem further, prescriptions, consultation referrals, patient education, and
recommended time to return for follow up.

Valid Documents
•Physicians
•Outpatient Consults
•Colonoscopy
•Operative Reports
•Interventional Radiology - Cardiac Catheterization
•IVC Filter Placement
•Pacemaker Insertion
•Emergency department Visits(always coded separately from inpatient visit).
•Discharge summary – Admit date and discharge date – If discharge date is not present at the discharge
summary it should be present at the same visit any type of document consider as valid (We can capture
Discharge date from Lab reports, X-ray, CT scan, etc.)
•If there is no discharge summary or discharge date, then break these and code as a separate line item and
consider as a physician type of visit.
•Physical therapy(code only once per year for a single condition. If PT was given for a different condition
during the same year, code that DOS also.)
•Occupational Therapy(similar to that of PT visit).
•House Call (as long as this is face to face encounter between patient and physician)
•Home visit (as long as this is face to face encounter between patient and physician)

Invalid Documents
•RN
•Nurse visit
•MS
•MA
•LPN
•Admit H&P (if not coding diagnosis from discharge summary).
•Intern notes
•PT INR(Coumadin Visit)
•INR
•Hospice
•Home Health Care Records
•Telephone encounters
•SNF
•Vaccine or injection visit
•Dr (Doctor is not a valid credential)
•RN, Nurse visit, MS, MA, LPN, intern notes, House surgeons – If face to face encounter visit is in complete
format with the signature of the above mentioned unapproved provider but co-signed by the approved
provider, then we can code from such visits considering it as a valid document.

Medical Record Issues
1.Provider signature missing – Code dx and select the issue
2.Provider signature does not meet CMS guidelines/credential missing–
Code dx and select the issue
3.Illegible Notes – Do not code, select the appropriate issue
4.Missing Face to Face Encounter - Do not code, select the appropriate
issue
5.No Chronic Conditions to Code (HCC dx) - Do not code, select the
appropriate issue
6.Patient Name Missing - Do not code, select the appropriate issue
7.Mixed Patient Record - Do not code, select the appropriate issue
8.Wrong Patient/Chart - Do not code, select the appropriate issue
9.Incomplete Documentation - Do not code, select the appropriate issue
10.Invalid Year for coding - Do not code, select the appropriate issue

Significant Changes to the 2014
Risk Adjustment Model
HCC changes:
• The new 2014 model has significant changes to HCCs when compared to the prior
model. These changes include potential negative impacts around HCCs related to
Chronic Kidney Disorder (CKD) and Diabetes potentially offset by additions to the
neurological metabolic areas. Please note that actual impact of the new model
will vary based on member mix on an individual plan basis. Overall, the 2014
model has 79 HCCs compared to 70 in the prior model. Below is a quick summary
of some of those changes (red = deleted, green = added, yellow = major change):

Significant Changes to the 2014
Risk Adjustment Model
Example:
Acute Chronic ICD9
ICD-9-CM
Description
2013
Payment
HCC
ICD-9-CM
Description
2014
Payment
HCC
ICD-9-CM
Description
2013
Payment
RxHCC
2014
Payment
RxHCC
AC 0031
Salmonella
septicemia
HCC2
Salmonella
septicemia
HCC2
A 00322
Salmonella
pneumonia
HCC112
Salmonella
pneumonia
HCC115
A 00323
Salmonella
arthritis
HCC37
Salmonella
arthritis
HCC39
AC 00324
Salmonella
osteomyelitis
HCC37
Salmonella
osteomyelitis
HCC39
AC 0064
Amebic lung
abscess
HCC112
Amebic lung
abscess
HCC115
Amebic lung
abscess
RxHCC 106RxHCC 106
AC 0074
Cryptosporid
iosis
HCC5
Cryptosporidi
osis
HCC6
Cryptosporidi
osis
RxHCC 5 RxHCC 5
A 0202
Septicemic
plague
HCC2
Septicemic
plague
HCC2
A 0203
Primary
pneumonic
plague
HCC112
Primary
pneumonic
plague
HCC115
A 0204
Secondary
pneumon
plague
HCC112
Secondary
pneumon
plague
HCC115
A 0205
Pneumonic
plague NOS
HCC112
Pneumonic
plague NOS
HCC115

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