Clinical Judgment Still Reigns: Why HCCs Must Reflect Active Condition Management

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.