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.
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.
- ICD-10 Trainings
- Comprehensive Courses
- CPC (Certified Professional Coder)
- COC (Certified Outpatient Coder)
- CIC (Certified Inpatient Coder) NEW!
- CRC (Certified Risk Adjustment Coder) NEW!
- CPB (Certified Professional Biller)
- CPMA (Certified Professional Medical Auditor)
- CDEO (Certified Documentation Expert – Outpatient) NEW!
- CPPM (Certified Physician Practice Manager)
- CPCO (Certified Professional Compliance Officer)
- VIEW ALL CERTIFICATIONS
Coding / Billing Solutions
- Audit / Compliance Solutions
Job Experience / Apprentice Removal
News / Discussion
- Other Resources
- Book Store
- Log In / Join