More is not always better for diagnosis coding

An element of getting paid that is likely to assume even greater significance in the years ahead is risk adjustment. In general, “risk adjustment” means modifying physician reimbursement to acknowledge that some patients are more difficult to treat than others.

A common method of risk adjustment is the use of hierarchical condition category (HCC) scores, which typically relate to the diagnoses associated with a patient. The subject has led some physicians to ask whether they should report diagnoses in addition to those addressed during a patient visit to ensure the best possible HCC score (and thus the best possible risk adjustment) for that patient.

First, it’s important to know that not all diagnosis codes are HCC risk-adjusted codes. Active diagnoses that are risk-adjusted and affect HCC scores should be submitted at least annually after Jan. 1 to be considered for risk adjustment purposes. Non-risk-adjusted codes are submitted only when addressed or considered with an encounter.

In the context of coding a visit or encounter, you should first report diagnosis codes that are used to support the medical necessity of the encounter. You should report not only the diagnosis codes that describe why a patient was seen but also any diagnosis codes associated with chronic conditions that affect treatment choices. For HCC purposes, additional conditions may also be dropped on the same claim regardless of whether they are related to the visit. But there are restrictions.

It is acceptable to submit a condition that is not addressed at the encounter, as long as the condition is active and affects overall patient care treatment or management. Many chronic conditions meet these requirements but don't necessarily directly support medical necessity of the evaluation and management (E/M) code or other codes reported for the encounter.   

ICD-10 guidelines state, in part:

Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management. Do not code conditions that were previously treated and no longer exist. However, history codes (categories Z80-Z87) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment.

Codes that “were previously treated and no longer exist” are not relevant to support the encounter and are not active for purposes of HCC scoring.

It is also important to note that the Medicare HCC model requires that conditions originate from face-to-face encounters (pathology is allowed) by an approved provider. In addition, there must be evidence in the medical record to reflect that the condition is active.

More information on diagnosis coding and risk adjustment can be found in the March-April 2018 issue of FPM.  

– Kent Moore, Senior Strategist for Physician Payment at the American Academy of Family Physicians (AAFP), and Samuel Le Church, MD, MPH, CPC, CRC, a family physician from Hiawassee, Ga., and the AAFP alternate advisor to the American Medical Association CPT Editorial Panel.