Hierarchal Condition Category (HCC) coding plays an increasingly important role in today’s ever-changing world of insurance benefits and reimbursement.  With the creation of the Affordable Care Act (ACA), HCC code capture is no longer only for  Medicare Advantage plans. 

What is Risk Adjustment? –  

Risk adjustment payment methodologies mean that insurance companies receive additional reimbursement for the illness burden of a particular patient rather than for quantity of services rendered.  Some health plans in turn share this increased revenue with providers.  Payments for HCC capture are paid prospectively, so diseases captured this year in 2016 won’t be paid until 2017.

Risk Scoring – ICD-10-CM codes are translated to one of 79 HCC categories.  Not all diagnoses are included in risk scoring, typically the diagnoses involved will be chronic diseases that are costly to care for.  For example, diabetes, CHF, COPD, malignant neoplasms, etc.  Most acute conditions are not part of risk scoring calculations because they are less costly.  However, there are some acute conditions like CVA, MI, hip fracture that are included in the plan.  Each diagnosis must only be documented and reported once per year to be included in risk scoring.

Provider Documentation – Official ICD-9-CM and ICD-10-CM guidelines state that accurate coding cannot be achieved without clear, consistent, complete documentation in the medical record.

Guidelines further instruct to:  Code all documented conditions that exist at the time of the encounter, and require or affect patient care, treatment or management

A simple list of problems or diagnoses is not acceptable documentation.   Documentation must prove that the patient’s condition(s) were monitored, evaluated, addressed and treated.  Additionally, compliant documentation must be legible and include a patient name, date of service and provider signature. 

How to ensure proper HCC capture – ICD-10 brought us increased code specificity and increased requirements for detailed documentation.  Work with your providers to make sure that they understand what is required with codes that they commonly use.  Make sure that manifestations of certain diseases are not overlooked.  For example, when coding diabetic nephropathy (E11.2X), make sure to follow your coding notes and also capture the CKD code (N18.X).  Additionally, we see all too often that chronic conditions are note assessed, addressed because the patient only comes in for a specific minor complaint.  Chronic conditions that might be managed by a specialist, get completely left out of the PCP documentation.  Make sure that your providers are assessing chronic conditions at least once a year as pertinent, so that documentation can be coded for capture of these conditions. 

Many times status codes are left off of billings and/or these diagnoses are never assessed.  History of amputation, ostomy status, transplant status and dialysis status are all commonly left out of provider assessments.  Another commonly forgotten diagnosis is alcoholism; even if in remission, this should be documented when it affects the care of the patient, so that it is codeable and   captured. 

If it isn’t documented we can’t code it, so ongoing documentation improvement is of utmost importance.  RMC offers a wide variety of coding, auditing and education services.  If you are interested in knowing more please let us know! 


By Monique Vanderhoof RHIT, CPC, CCA, CRC – Director of Specialty Coding Services at RMC, Inc.