AHA Coding Clinic on Chronic Conditions, in HCC Context


Colorado Springs, CO
Best answers
Looking for some opinions on the following:

When coding HCC diagnoses for Medicare Risk Adjustment (Medicare Advantage plans), does the following information from Coding Clinic imply that there does not need to be any evidence of evaluation or treatment of a -chronic- condition (which is not well defined) in order to code the condition? I would particularly note that we are reviewing the professional-side records (mostly outpatient) for our HCC coding.

If it does indeed mean that no such evidence is necsesary, this violates my personal understanding and my RADV experience regarding what CMS will consider as acceptable documentation for HCC purposes. AHA Coding Clinic is geared toward hospital inpatient coding and is not intended to address HCC coing in particular.

Opinions from other coders are very welcome... thanks.

-Tim Buxton


The American Hospital Association, in its "Coding Clinic" publication (3rd Quarter, 2007, pages 13-14), has stated the following:

Clarification, Reporting of Chronic Conditions

Recently, the Central Office has received multiple lettersrequesting clarification regarding whether chronic conditions such as hypertension, congestive heart failure, asthma, emphysema, COPD, Parkinson'sdisease, and diabetes mellitus are always reportable.

Chronic conditions such as, but not limited to, hypertension, congestive heart failure, asthma, emphysema, COPD, Parkinson's disease, and diabetes mellitus are reportable. The Uniform Hospital Discharge Data Set (UHDDS) defines "Other Diagnoses" as "all conditions that coexist at the time of admission, that develop subsequently, or that affect the treatment received and/or the length of stay. Diagnoses which relate to an earlier episode which have no bearing on the current hospital stay are to be excluded."

For reporting purposes, chronic conditions need to meet the UHDDS definition of "other diagnoses." According to the OfficialGuidelines for Coding and Reporting:

For reporting purposes the definition for "Other diagnoses" is interpreted as additional conditions that affect patientcare in terms of requiring:
Clinical evaluation; or
Therapeutic treatment; or
Diagnostic procedures; or
Extended length of hospital stay; or
Increased nursing care and/or monitoring

This is consistent with information previously published in Coding Clinic Second Quarter 1992, pages 16-17; Second Quarter 1990, pages12-13; and July-August 1985, page 10.
I have been working on HCC coding for last two years and this is absolutely not true, at least in outpatient coding. HCC coding should be done on MEAT rule, which is monitor, exam, assess, and treat. If all of these are not met, an HCC is not validated and no use to code it. Others' views are welcome.
Hi Tim,

I recently attended an HCC Best Practices seminar in which this issue was discussed and it was commonly agreed that in order for a diagnosis to be reportable there must be evidence of evaluation/management. The most valuable testimony to this view was presented by a carrier who had survived a RADV audit. The MEAT acronym is an easy one to remember and even though there are variations on what the acronym stands for the message is the same: there must be evidence of evaluation/management.

The OIG recently published a final report on PacifiCare of Texas' RADV audit conducted in 2007. It was an interesting report and what I found most informative was the Appendix C in which PacifiCare responds to each claim specifically. Even though we don't have the benefit of seeing the chart notes I think it's evident by PacifiCare's responses what the issues were. Here's a link to that report:


It seems that one of the differences between hospital and outpatient coding is that the hospital coder seems to have a little more leeway in determining which diagnoses are reportable (diagnoses that “affect the treatment received and/or the length of stay”) and the source of those diagnoses (lab, x-ray, etc.), whereas outpatient documentation must be explicit and documented by the provider (no lab, no x-ray). I would be interested in hearing from a hospital coder about this difference, especially one who has HCC experience, as well.

Thank you for posting your question. There are fewer resources and discussions for HCC coders since this reimbursement model is relatively new to the scene. I appreciate the opportunity to share information.

I?m a HCC Coder and we are having a Debate on if we are allowed to use a Medication list as the Sole support of an HCC Code. Example, if the patient has COPD and the only support in the Medical Record is Advair (from a medication list), Is this the correct way to support an HCC Diagnosis?
medication list as MEAT

As a HCC coder we have been told that the medication must be linked to the condition by the provider to show Meat. I suppose the reasoning is that many medications are used to treat several different conditions.
Risk Adjustment Manual Chapter

The risk adjustment manual states CMS defers to ICD-9 guidelines when determining the proper diagnosis.