How to Avoid the 10 Most Common Hierarchical Condition Category Coding Errors

The Centers for Medicare & Medicaid Services (CMS) conducts medical record reviews each year to validate the accuracy of risk adjustment data and payments made to Medicare Advantage Organizations (MAOs). Risk adjustment data validation (RADV) ensures that appropriate payments have been made to MAOs. Humana participated in the 2007 national sample.

While collecting and reviewing the medical records for the RADV07 National Sample, Humana identified the most problematic Hierarchical Condition Category (HCC) codes. These HCCs were most likely to have validation problems and/or lack support in the associated medical record. The problematic HCCs and the common errors associated with them are listed below.

1. HCC105 - Vascular Disease
When documenting vascular diseases, physicians should be as specific as possible and document any pertinent signs or symptoms (pain; cramping or fatigue in the legs, buttocks or feet; cold feet, etc.) and/or radiological findings (X-rays, ultrasound/Doppler studies, angiography, etc.) which may further support the condition. This will allow the coder to determine the specific HCC within the vascular disease category, which includes peripheral vascular disease (PVD) (443.9), peripheral artery disease (PAD) (443.9), intermittent claudication (443.9), abdominal aortic aneurysm (AAA) (441.4) and deep vein thrombosis (DVT) (453.40). Also, physicians must document as legibly as possible; PVD may be mistaken for PUD (peptic ulcer disease), leading to incorrect coding as well as future clinical issues.

2. HCC16 - Diabetes w/Neurological Manifestations
Physicians must specifically document complications of diabetes mellitus (e.g. nephropathy, neuropathy, angiopathy, etc.) as "diabetic" or "due to diabetes" in order for these disease processes to be coded appropriately. Without this documentation, no cause-and-effect relationship can be assumed. The diabetes must be properly linked to the manifestation using terms such as "with," "due to" and "secondary to." For example, the medical record must state "diabetes with neuropathy" or "diabetic neuropathy."

3. HCC71 - Polyneuropathy
In order for this HCC to be validated, the medical record must specify a diagnosis of polyneuropathy. If the documentation simply says "neuropathy" without reference to a specific type, the appropriate code is neuropathy, unspecified (355.9). This also is true of other types of neuropathy, such as peripheral neuropathy (356.9) and peripheral autonomic neuropathy (337.9).

4. HCC82 - Unstable Angina/Acute Ischemic
Unstable angina is most often a sign of an impending myocardial infarction and requires emergency treatment and/or hospitalization. Therefore, it is not often used in an office setting. More likely, the stable angina (angina that is relieved with rest and/or medication) (413.9) or Prinzmetal's (variant) angina (413.1) is more appropriate. To avoid this error, the physician needs to be very specific when documenting angina.

5. HCC92 - Specified Heart Arrhythmias
If the physician does not specify the type of heart arrhythmia (e.g., atrial fibrillation, atrial flutter, sick sinus syndrome, severe or persistent sinus bradycardia, etc.) then it should be coded as cardiac (heart) dysrhythmia, unspecified (427.9).

6. HCC10 - Breast, Prostate, other Cancers (154 codes in this HCC)
7. HCC9 - Lymphatic, Head and Neck, other Cancers
(410 codes in this HCC)
Both of these code series are for cancers that are current conditions. If the patient has a history of cancer, but there is no current evidence of an existing malignancy and no current treatment, the cancer should not be coded as a current condition. When a primary malignancy has been previously excised or eradicated from its site, there is no further treatment directed to that site, and there is no evidence of any existing primary malignancy -- a code from personal history of malignant neoplasm (V10) should be used to indicate the former site of the malignancy. If the patient is still under active or current treatment for malignancy of primary site (i.e., radiation or chemotherapy), retain the code for malignancy of primary site.

8. HCC96 - Ischemic or Unspecified Stroke
This HCC should not be coded from a physician's office or progress note unless the documentation specifically states that the cerebral vascular accident (CVA) or stroke occurred during the office visit. An acute stroke is typically only coded during the initial episode of hospital care. In an office setting, it is more likely that the patient is presenting for follow-up post-CVA. A "history of" or "late effect" HCC for CVA should be used (V12.54 history of CVA with no residual deficits). It also is important to document any deficits from the CVA. As a reminder, when coding, terms such as "weakness" is not the same as "hemiparesis." (Late effects of CVA with specific deficits is classifiable to use codes in category 430-437 and 438.9 to identify deficit.)

9. HCC108 - COPD
There are several conditions, which fall within the COPD group; some of those conditions include: chronic bronchitis, emphysema, chronic obstructive asthma. If these conditions are listed in addition to COPD the codes are as follows: Chronic bronchitis (491.20), emphysema (491.20), chronic obstructive asthma (493.20). If COPD is not listed then the correct codes are as follows: Chronic bronchitis (491.9), emphysema (492.8). In order to ensure accuracy of coding these chronic respiratory conditions, the physician is encouraged to document as specifically as possible.

10. HCC31 - Intestinal Obstruction
This HCC is intended for acute intestinal obstruction, including acute and chronic peptic ulcer with perforation, paralytic ileus, intussusception, impaction of intestine, peritonitis, etc. These conditions more commonly are seen in an acute care setting. In an office setting, it is more likely that a code for history of intestinal obstruction is appropriate. V12.79 is used for unspecified history of intestinal obstruction; other codes in the group are available for specificity, such as V12.71 for history of peptic ulcer disease. The appropriate code will vary depending on provider documentation.

Improving the accuracy of documentation and coding may speed up claims processing and facilitate reimbursement.

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