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That’s an HCC?

Each year the impact of risk adjustment using CMS-HCCs is being recognized progressively more by those involved in any aspect of Population Health. Medicare Advantage organizations, Medicare Shared Savings Plan ACOs, physicians participating in MIPS, and participants in hospital-centric quality programs all greatly affected by this risk adjustment model. 

But many providers, coders and CDSs involved in the process of proper documentation and submission of ICD-10-CM codes are unaware of some common conditions with risk adjustment impact that are often overlooked by providers.   

The following is a clinical vignette to help understand some of these missed conditions. 

Mr. Brown is a 67-year-old male who presents to his PCPs office to follow up on his unintentional weight loss. He is accompanied by his wife of 45 years, Erma. She states her husband’s dementia seems to be worsening. He is easily agitated and has even swung at her from time to time. She states his appetite is decreasing and his clothes are starting to “hang on him”.  


General: weight loss, poor appetite. No night sweats, fevers. His wife makes sure he takes his medications. He has continued to abstain from alcohol for 5 years since he was admitted to the hospital in withdrawal. 

Respiratory: his smoker’s cough is no worse than it has been for the past 10 years when he completely stopped smoking. No wheeze, no hemoptysis. Only mild SOB. 

Cardiovascular: He continues his “heart medicines” (with his wife’s encouragement) and has no chest discomfort, lightheadedness, edema, palpitations. His aspirin seems to be causing easy bruising of his forearms and backs of his hands. 

GI: unremarkable.  

Neuro: no new deficits. Psych: worsened memory, increased difficulty with word-finding, outbursts of agitation. 

Exam: Vital signs stable (VSS)BMI now 17 from 24 (6 months prior)Gen: Cachectic-appearing male who now yells at me when I attempt to auscultate his chest, grabbing my stethoscope. ENT: unremarkable. Lungs and heart are difficult to assess due to patient’s noncompliance and agitation. Abdomen: limited exam but benign. Extremities: senile purpura diffusely are forearms and dorsum of hands. Thin skin. Neuro: grossly intact. Psych: confused, agitated. Does not answer questions but alert. 

CXR done 3 months ago was reviewed: Normal lugs and cardiac contours. Aortic atherosclerosis is apparent. Otherwise unremarkable. 

Impression/visit diagnoses: 

  1. Worsening dementia, Alzheimer’s type: now with increased agitation and episodic violent outbursts 
  2. CAD with HTN: stable on Imdur, ASA, carvedilol, lisinopril, statin.  
  3. Cachexia: substantial drop in weight/BMI, likely due to poor dietary intake. 
  4. Aortic atherosclerosis; noted incidentally on CXR 


  1. Adding Seroquel. Referring to dementia clinic 
  2. Encourage use of small frequent meals with Ensure supplements 
  3. Continue ASA, statin, beta blocker, lisinopril for CAD, HTN and aortic atherosclerosis 
  4. F/u with me in 4 weeks. 


Captured HCCs (sufficiently validated with a MEAT criterion): 

  • G30.9 (with F02.81) Alzheimer’s disease with behavioral disturbance: patient has moved from HCC 52 to HCC 51 with higher weight 
  • R64 Cachexia captures HCC 21 
  • I70.0 Aortic atherosclerosis captures HCC 108 
  • While this provider did not include the dx among visit diagnoses, because one can code from the entire encounter, could capture  
    • D69.2 senile purpura for HCC 48  
    • Smoker’s cough codes to J41.0, Simple chronic bronchitis, HCC 111 

Missed HCC opportunities that also satisfied MEAT criteria: 

  • I25.11 Atherosclerotic heart disease of native coronary artery with angina pectoris, HCC 87; need to clarify if the Imdur is used to suppress angina to capture this code 
    • If a medication like a nitrate is used to suppress angina, the angina can be captured (but do not capture as “unstable”) 
    • This concept also applies to persistent atrial fibrillation that currently is in normal sinus rhythm due to an antiarrhythmic like sotalol, amiodarone, etc. 
  • F10.21 Alcohol dependence (patient had episode of withdrawal), in remission, HCC 55 
    • Note: the term “alcoholism” is sufficient to code from F10.2- (alcohol dependence) code set

Educating your providers regarding some of these common conditions can help to better describe your patient population’s medical complexity. This, in turn, will help give your providers credit for caring for a sicker population while helping your MAO and ACO to financially thrive. Patients will then be more likely to have needed resources provided to help slow the progression of their chronic illnesses. 

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