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Thread: Coding for Risk Adjustment (HCCs)

  1. #1
    Join Date
    Apr 2007
    St. Louis West, MO

    Question Coding for Risk Adjustment (HCCs)

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    When pulling diagnosis information for risk adjustment from outpatient/physician notes, there is some confusion whether or not to code diagnoses that are listed in PMH. CMS guidance is vague, at best.

    Arguments include:
    - Code everything listed in the PMH because if the doctor put it in PMH the doctor had to take it into consideration for MDM. (However, that isn't always the case, especially with the new EMRs which autopopulate previous coding data into the PMH).
    - Code from PMH only when it is clear the condition played into the MDM on that particular DOS. If it wasn't documented as such, it wasn't done.
    - Code nothing from PMH because if it did play into MDM it should also appear in the assessment section.

    I'd like to know your individual thoughts and which of the three opinions above most closely matches your coding practice. I appreciate your opinions and feedback! Thanks!

  2. #2


    I have always coded from just what the provider says under his impression/assesment. All because it is in the PMH doesn't mean that the provider addressed the condition on that date of service, so my thought would be you only pull codes that were addressed for that date of service. I have read somewhere that you can look at the PMH for clarity of a code from the assesment but not code from it. Hope this helps!


  3. #3
    Join Date
    Apr 2007
    North Central Florida


    Many times a PMH or problem list is not updated and can be inaccurate when coding to capture conditions that the patient has and is being treated for now. I do use the PMH for clarification but code primarily from the assessment/plan portion of the note.

  4. #4


    I've always been instructed to only code from PMH if there's a chronic condition listed. As far as just coding from the Assessment could be tricky as well. For example, you may have Prostate CA listed in your PMH as well as under your impression, but it still doesn't mean it was Assessed just because its written under your impression unless there's a note beside it or indication that the Cancer is active & on that DOS there's no other documentation addressing the Cancer, its just written under the impression. It must show evaluation/assessment and/or treatment for the Cancer. Hope this helps!!!!

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