November 07, 2017 | | Comments 0
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Guest post: Compliance risks abound in HCCs

James Kennedy, MD, CCS, CDIP

James Kennedy, MD, CCS, CDIP

by James S. Kennedy, MD, CCS, CDIP

Let’s discuss the compliance risks CDI and coding professionals need to address related with hierarchical condition categories related to the MACRA.

Coding must be based on provider documentation, not what is entered on a superbill or computer software. ICD-10-CM code assignment is based solely on a provider’s documentation in the legal medical record, according to the 2017 ICD-10-CM Official Guidelines and Coding Clinic, Fourth Quarter, 2016, pp. 147–149. The problem is that many physicians document one way in their notes and then pick an ICD-10-CM code in their billing software or superbill that would not be assigned if one applies ICD-10-CM coding conventions based on the provider’s documentation. 

For example, “uncontrolled diabetes” documented in the medical record does not code to diabetes with hyperglycemia (which is a higher-weighted HCC than unspecified diabetes). “Sepsis syndrome” documented in the EHR may not be coded as sepsis unless the physician states “sepsis” or “severe sepsis.” The ICD-10-CM Official Guidelines for Coding and Reporting state that R53.2 (functional quadriplegia), a very highly weighted HCC, may not be coded unless this exact term is documented in the medical record. If a physician picks R53.2 in the billing software but does not document “functional quadriplegia” in the progress note, this is likely to be deemed a false claim.

ICD-10-CM rules for physicians and outpatients differ from inpatients. Unlike inpatient facilities, no physician may submit an ICD-10-CM code for an uncertain condition, one qualified as possible, probable, likely, suspected, still to be ruled out, or other similar language, even if the documentation occurred at an inpatient facility. In the same manner, uncertain diagnoses cannot be provided for inpatient rehabilitation or outpatient observation care since the Guidelines limit these to short-term and long-term acute care facility and inpatient psychiatric facilities. On the other hand, Coding Clinic, Third Quarter, 2009, p. 7 allows for conditions termed as “evidence of” to not be uncertain and, thus, codable in the outpatient or physician environment. How one differentiates terms like “evidence of” or “consistent with” requires the judgment of an English professor.

While an inpatient facility may assign “chronic systemic conditions” documented in the history as additional diagnoses, even if they are not treated, every diagnosis addressed in the physician (or other outpatient) encounter must have documentation of how it was monitored, evaluated, assessed, or treated. A physician cannot just export the patient’s problem list to a billing sheet unless there is evidence in the encounter that the conditions that are coded and billed were addressed.

Physicians must explicitly explain why conditions affecting HCC assignment were pertinent to the patient’s care. For example, even if treating an alcoholic, sober for 20 years while maintaining his or her program, the provider must substantiate that he or she did assess that patient and ascertained that the patient’s dependency was indeed in remission.

Get to know the Recovery Audit Data Validators (RADV). If you’ve never heard of the RADVs, learn about them at CMS’ website, and look at their data validation checklist, available here. Here’s a sample of what they are looking for:

  • Is the record for the correct enrollee?
  • Is the record from the correct calendar year for the payment year being audited (i.e., for audits of 2011 payments, validating records should be from calendar year 2010)?
  • Is the date of service present for the face-to-face visit?
  • Is the record legible?
  • Is the record from a valid provider type (hospital inpatient, hospital outpatient/ physician)?
  • Are there valid credentials and/or is there a valid physician specialty documented on the record?
  • Does the record contain a signature from an acceptable type of physician specialist?
  • If the outpatient/physician record does not contain a valid credential and/or signature, is there a completed CMS-generated attestation for this date of service?
  • Is there a diagnosis on the record?
  • Does the diagnosis support an HCC?
  • Does the diagnosis support the requested HCC?

Consider using an internet search engine to learn how RADVs are scrutinizing HCC capture, recognizing that this scrutiny will likely extend to physician practices to ensure physicians are not “upcoding” their records. The U.S. Government Accountability Office report on HCCs is required reading.

Editor’s note: Dr. Kennedy is a general internist and certified coder, specializing in clinical effectiveness, medical informatics, and clinical documentation and coding improvement strategies. Contact him at 615-479-7021 or at This article originally appeared in Briefings on Coding Compliance Strategies. Opinions expressed are that of the author and do not necessarily represent HCPro, ACDIS, or any of its subsidiaries.


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Filed Under: ACDISCDI ProfessionClinical Documentation ImprovementComplianceOutpatientphysician advisor


Linnea Archibald About the Author: Linnea Archibald is the CDI editor for the Association of Clinical Documentation Improvement Specialists (ACDIS). In this role, she helps out with the website, blog, social media, newsletter, and the CDI Journal. If you have any questions, feel free to email her.

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