Friday, May 10, 2013

Clinical Documentation Improvement Tips - HCC Coding

Clinical Documentation Improvement Tips - HCC Coding

* Clinical Documentation Improvement will be the key to a successful transition into ICD-10.
Over the last two years, I have been teaching medical professionals how to code and document compliantly - specifically HCC Documentation and Coding.

I have listed below the most common errors that I find when auditing medical records. 

• Don’t document “H/O” of any disease that currently exists.
– The statement “history of” in ICD-9 terms means that the patient no longer has this condition. However, “H/O” is ok when documenting some status conditions such as an Amputation, Old MI or Cancer
• Rule of thumb in coding is
– If a patient is on a medication for a condition and if the medication were to be stopped, would the condition resume, and the answer is mostly likely or yes, then you still code the condition.

– H/O CHF – pt is on lasix 428.0
– H/O Angina – pt has nitroquick 413.9
– H/O COPD – pt is on Advair 496
• This also applies to a pacemaker for SSS or Complete or 3rd degree heart block…if the SSS or Heart Block is documented you can still code it 427.81 or 426.0


• Alcohol dependence, Chronic alcoholism or Alcoholism in remission 303.90 & 303.93
• Drug dependence or Drug dependence in remission
• (opiate, anxiolytic, sedative, hypnotic, hallucinogen or amphetamine) 304.90 & 304.93
• Patient has arrived at a stage of physical dependency and would experience physical signs of withdrawal with sudden cessation
 **Alcohol abuse and drug abuse are not HCC’s 305.XX

Major Depression 296.XX

– PHQ9 score >10
– 5 of 9 DSMIV criteria
– Medication
– Following with a mental health provider
– **if only “Depression” 311 is documented…it is not an HCC code!


Must have current treatment to the site
Treatment to the site is considered:
• Chemotherapy, Radiation or Adjunct therapy
• Or if patient elects not to have any treatment
Breast Ca (174.9) – on Tamoxifan, Arimidex, Femara etc. would be considered adjunct therapy
• Documentation needs to say “Breast Ca onTamoxifan”
• If not then H/O Breast cancer V10.3
Prostate Ca (185) – on Lupron, Casodex or Zoladex would be considered adjunct therapy
• Documentation needs to say “Prostate Ca on Lupron”
•If not then H/O Prostate Ca. V10.46


• Mets is the highest HCC $17,753 only if the site it has metastasized to is documented
– H/O Breast Ca with Mets to lung V10.3 & 197.0
– Prostate Ca on Lupron with bone Mets 185 & 198.82
– H/O Colon Ca with Mets to the liver V10.05 & 197.7
If you document like this the highest HCC opportunity will be missed

– Metastatic Breast Ca $1622 (if Breast ca is under treatment) 174.9 & 199.1
– Metastatic Colon Ca $1622 (if Colon ca is under treatment) 154.0 & 199.1
– Lung Ca with Mets $8213 (if Lung ca is under treatment) 162.9 & 199.1
– H/O Lung Ca with Mets $1622 V10.11 & 199.1


Acute condition that can only be documented and coded during the initial episode of care – 434.9X
– Once the patient is discharged from hospital documentation should reflect:
  “h/o CVA, s/p CVA or Old CVA V12.54”
• Late effects of CVA should be documented and coded as such
– CVA with hemiplegia/hemiparesis 438.20
– CVA with dysphagia 438.82


Acute DVT (initial episode of care)
– 453.40
Chronic DVT (on an anti-coagulant)
– 453.50
H/O DVT (not on an anti-coagulant)
– V12.51
Need to document “chronic DVT” if patient is on an anti-coagulant
*** Same guidelines for Pulmonary Embolism


• Artificial openings
– Gastrostomy V44.1
– Colostomy V44.3
– Tracheostomy V44.0
– Ileostomy V44.2
• Amputations
– BKA V49.75
– AKA V49.76
– Foot V49.73
– Toe V49.71 or V49.72
• AAA – Abdominal aortic aneurysm – 441.1 (w/o repair)
• Aortic Atherosclerosis – 440.0

Contact Kameron Gifford, CPC at ERM Consulting for a free Revenue Risk Assessment 

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