Beyond the List: CMS Demands Clinical Relevance
Today, CMS expects that each submitted HCC reflects an actively managed condition, not a passive mention or old record. That means you need to show your work — labs, medications, referrals, and progress notes that prove the condition is still relevant, still monitored, and still part of the care plan.
Real Example: Chronic Kidney Disease (CKD)
Let’s break it down with a common example: CKD.
Correct HCC Submission:
Diagnosis: Chronic Kidney Disease
Documentation includes:
Recent lab work (e.g., eGFR or creatinine trends)
Current medication regimen (e.g., ACE inhibitors)
Specialist involvement, such as a nephrology consult
Evidence in the progress note that CKD is being addressed at the visit
This paints a complete, current, and actionable clinical picture.
Incorrect Submission:
Diagnosis listed: CKD
No recent labs, no medication updates, and no mention in provider notes
No indication that the condition is being monitored or treated
This type of submission may trigger audits or get flagged as unsupported — even if the diagnosis is technically accurate.
Clinical Coding Tip: Reaffirm Condition Activity at Every Visit
One of the simplest but most powerful habits to build into your workflow is this:
Use each visit to reaffirm the condition’s activity.
This doesn’t mean you have to do a full workup every time — but you should:
Reference recent labs or imaging
Note ongoing medication use or changes
Mention specialist referrals or prior visits
Describe symptoms or the absence of symptoms with monitoring
A short line in the note like “CKD Stage 3 remains stable, monitored with eGFR every 6 months, managed with lisinopril” can make all the difference.
Why This Matters More Than Ever
Here’s the bigger picture: CMS is actively tightening standards around risk adjustment documentation — especially under increasing RADV audit activity.
Plans and providers that submit codes without supporting evidence risk:
Clawbacks of payments
Failed audits
Compliance flags
Loss of trust in data integrity
But plans that show active, ongoing management not only protect their risk scores — they also ensure that patients are getting the level of care their conditions require.
How Coders and Providers Can Work Together
For Coders:
Don’t just look for a code — look for proof.
Query providers when documentation doesn’t reflect active care.
Educate your teams on the difference between “on the list” and “being managed.”
For Providers:
Be specific in your progress notes.
Avoid copying forward old diagnoses without current context.
Include actionable phrases like “monitored,” “managed,” or “treated.”
Final Thoughts: The Human Side of Coding
Risk adjustment is a data-driven model — but it depends on real, ongoing care.
At the heart of it is clinical judgment, the provider's decision to monitor, treat, or refer based on the patient’s needs today — not just what was on the chart last year.
So the next time you document a chronic condition, ask:
“Is this diagnosis still active, and have I shown that in the note?”
If yes, your coding will stand strong. If not, it’s time for a quick update — for the sake of compliance, care, and accuracy.
Need help aligning your clinical documentation with HCC coding best practices? Reach out to sales@healthdatamax.com or visit healthdatamax.com to connect with our team.