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Case study: Why capturing all diagnoses is critical with HCC coding

When coding under a risk-adjustment paradigm, capturing the full range of a patient’s chronic conditions takes on elevated importance. That’s because your payments, and ultimately your coding compliance, may be impacted.
A look at a brief case study of a patient with multiple chronic conditions sheds light on how accurately capturing diagnosis codes can skew your risk-adjustment scores, explains Brenda Edwards, CPC, a coding and auditing consultant speaking at the 2018 Advanced Specialty Coding, Compliance & Reimbursement Symposium in Lake Buena Vista, Fla.
Exam: Patient is a 72-year-old female with symptoms of a urinary tract infection (UTI). Patient complains of fatigue, low energy and poor appetite. Patient is status post myocardial infarction 18 months ago. Patient appears frail and with mild malnutrition. Has lost 23 pounds in the last four months. Patient has been complaining of pain with urination, weakness and has had dry, itchy skin for the past several months. U/A done today shows WBCs, leukocyte esterase and microalbuminuria. Serum creatinine is 1.5.
Past medical history: Type 2 diabetes, chronic kidney disease secondary to diabetes, history of BKA skin intact at stump, no erythema. History of MI. Previous UTI four months ago with a serum creatinine of 1.6. Lab results at that time revealed stage 2 CKD.
Assessment and plan: Diabetes‐Metformin 500 mg UTI. Malnutrition‐Ensure and nutrition consult. RTC in six weeks. Referral made to Dr. Smith, a nephrologist, for CKD. Note electronically signed by John Anderson, MD 10/11/2018.
“This is a ton of good information,” says Edwards. She adds that the perception of the coder who is working under a risk-adjustment model may, or should, have shifted.
“In a typical world of where we used to be, you may come up with two diagnosis codes,” Edwards says. For instance, a coder may typically submit E11.9 (Diabetes mellitus without complications, type 2) and N39.0 (Urinary tract infection), only the former of which risk adjusts to a hierarchical condition category (HCC).
But in the burgeoning world of risk-adjustment coding, which applies to Medicare Advantage and other federal plans, coders should take a finer-toothed comb to the encounter details, Edwards advises. With a sharper focus on underlying and active conditions, you would be able to identify a full five ICD-10 codes that are linked to HCCs. In summation, here are the codes that the record would indicate:
  • E11.29 (Diabetes with renal manifestation, type 2)
  • N18.2 (Stage 11 chronic kidney disease)
  • E44.1 (Malnutrition of mild degree)
  • N39.0 (Urinary tract infection)
  • I25.2 (Prior myocardial infarction)
  • Z89.519 (Amputation, below knee)
Essentially, you’ve tapped into a host of “additional opportunities” to add important nuance to your diagnosis coding. All but the UTI code correspond to a HCC, which means the payments available to cover your patient’s likely cost of care are going to accurate. “Your coding is going to have a lot more value to it by bringing in all of those chronic conditions,” Edwards says.
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