DecisionHealth, DecisionHealth - 2019 Issue 10 (October)

Complications drop off HCC risk scores if your provider doesn’t address them

Question: Say a doctor sees a diabetic patient, notes blood sugar and increases the insulin dose. The chart includes diagnosis codes for diabetes mellitus (DM) with nephropathy (E11.21) and polyneuropathy (E11.42), but the notes do not otherwise address the polyneuropathy and nephropathy. For risk adjustment purposes, would this map to hierarchical condition category (HCC) 18 (Diabetes with chronic complications) or to HCC 19 (Diabetes without complication)? And if the nephropathy and polyneuropathy are not addressed in encounters, would the patient map to HCC 19, notwithstanding that he was diagnosed with them?

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