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HCC Coding Tips
Remember to keep in mind these common documentation faux pas! Missing Chief Complaint The chief complaint supports the medical necessity for the patient encounter. All visits require a chief complaint to be clearly documented. (Think, Follow up for hypertension, instead of 6 month follow up; or Patient seen today for…, instead of Observation day 2.)...
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Heart failure documentation must include the following key elements: 1. Type of heart failure Diastolic Systolic Combined Diastolic and Systolic Note: Documentation of Systolic and/or Diastolic Dysfunction does not equate to the type of heart failure. Heart failure and dysfunction are not interchangeable terms; documentation needs to state the type of “heart failure.” 2. Acuity...
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Documentation for risk adjustment Quick reference guide
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The Diagnostic and Statistical Manual of Mental Disorders (fifth edition) defines major depression as an individual experiencing five or more symptoms during the same two-week period, with at least one of the symptoms being either depressed mood or loss of interest or pleasure. Major depression symptoms include: Depressed mood most of the day, nearly every...
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Common CMS-HCC Diagnosis Codes* Information for Physicians/Allied Health Providers (AHP’s)
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This information is available in presentation format.
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Why is it important to capture the full burden of illness? When you document all of a patient’s chronic conditions accurately at least annually and code to the highest level of specificity, you’re helping your patient get the right care at the right time. By documenting and coding all conditions, you’re ensuring that your records...
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