Diagnosis Coding for Value-Based Payment: A Quick Reference Tool

 

Use this cheat sheet to identify diagnosis codes that are weighted for risk adjustment.

Fam Pract Manag. 2018 Mar-Apr;25(2):26-30.

Author disclosures: no relevant financial affiliations disclosed.

Diagnosis codes are increasingly used by accountable care organizations and others using alternative payment models to assess the health status of patient panels. By mapping ICD-10 codes to Hierarchical Condition Categories (HCCs), payers can factor severity of illness into value-based payment calculations, including shared savings allocations. Skeptical physicians may expect “HCC coding” to require more time clicking boxes with additional risk for payment cuts. However, we have found that by using a simple workflow intervention and tool, phy-coding is informed by HCCs and optimized for payers' risk adjustment calculations. Here's how it works.

First, identify which of a patient's chronic conditions have diagnosis codes weighted for risk adjustment. Qualifying diagnoses are typically specific, chronic, and predictive of significantly higher health costs. Electronic health record (EHR) systems can help with this process, but physician familiarity with these codes is still essential. For this reason, we created a three-page reference tool listing common diagnoses and the HCC weight for each one. We post it near our computers, where we can glance at it as we review our patient's problem list before the encounter. Our EHR time-stamps when a given problem was last updated. This information and the tool help us choose which chronic conditions to address during the visit and guide our coding for the encounter. (See “ICD-10 — HCC coding reference for family medicine.”)

KEY POINTS

  • Understanding Hierarchical Condition Categories (HCCs) and annually reporting ICD-10 codes that correspond to them is vitally important under new payment models that shift financial risk to physicians.

  • Using a quick reference tool that lists ICD-10 codes that have HCC weights can help busy practices make sure their coding accurately reflects their patients' complexity.

For example, consider Mr. White, a 62-year-old male who was seen in our clinic for a new patient visit. He had been seen in our health system in the past, so his medical history was well-documented in our EHR. A quick review of his problem list showed 19 chronic conditions. Comparing this list with our reference tool, only one — chronic hepatitis C status (ICD-10 code B18.2) — has an HCC weight. This was one of several conditions we addressed during his appointment, and we made sure to code for it and document the current status of the condition and plans for addressing it. Many common chronic conditions, such as Mr. White's hypothyroidism and essential hypertension, do not correspond to HCCs. Mr. White's problem list also includes “depression with anxiety” (F41.8). We scheduled a follow-up appointment for Mr. White in one month to discuss his mood concerns and requested records from his previous therapist. If we determine that Diagnostic and Statistical Manual of Mental Disorders criteria are met, “major depressive disorder, recurrent” (F33.9) or “major depressive disorder, in partial remission” (F32.4) might be a more appropriate diagnosis. Both have HCC weight.

Clinics in value-based payment settings must document and report as many qualifying diagnoses as possible for each patient annually. This should be a natural extension of taking a thorough medical history and addressing chronic conditions and health concerns in a consistent manner. We advise using your EHR's problem list feature to track relevant diagnoses, comparing them to our coding tool, and paying hawk-like attention to when they were last addressed.

ICD-10 — HCC CODING REFERENCE FOR FAMILY MEDICINE

 Download in PDF format

If your patient has any of these problems, document the diagnosis, assessment, and plan, and report the corresponding code annually.

ExamplesICD-10HCC1HCC weight2Notes

Type 2 diabetes (T2D)

T2D without complications

E11.9

19

0.104

Always has HCC weight. Document as specifically as possible.

T2D with hyperglycemia

E11.65

18

0.318

T2D with hypoglycemia, no coma

E11.649

18

0.318

T2D with mild retinopathy

E11.329

18

0.318

T2D with diabetic chronic kidney disease (CKD)

E11.22

18

0.318

T2D with polyneuropathy

E11.42

18

0.3168

Long term (current) insulin use

Z79.4

19

0.104

Hypertension (HTN)

HTN with congestive heart failure (CHF)

I11.0

85

0.323

Isolated essential HTN has no HCC weight. Relationship must be explicitly documented.

HTN + CKD stage 5/end stage renal disease (ESRD)

I12.0

136

0.237

HTN + CHF + CKD stage 1–4

I13.0

85

0.323

HTN + CHF + CKD stage 5/ESRD

I13.2

85

0.323

HTN + heart disease (no CHF) + CKD 5/ESRD

I13.11

136

0.237

Chronic kidney disease (CKD)

CKD stage 4, glomerular filtration rate (GFR) 15–29

N18.4

137

0.237

No HCC weight unless stage 4 or worse, or associated with HIV.

CKD stage 5, GFR <15

N18.5

136

0.237

ESRD

N18.6

136

0.237

Major infections

HIV/AIDS

B20

1

0.312

Active infections — serious, systemic, opportunistic, or bone/joint/muscle.

Sepsis

A41.8

2

0.455

Cancer

Breast cancer

C50.9

12

0.146

Active cancers — new, under treatment, or treatment declines — with documentation of any metastases.

Prostate cancer

C61

12

0.146

Lung, gastrointestinal, or pancreatic cancers

Varies

9

0.970

Metastasis to lymph nodes

C77.X

8

2.625

Hematologic problems

Myelodysplastic syndrome

D46.9

46

1.388

Aplastic anemia

D61.9

46

1.388

Acquired coagulopathy

D68.4

48

0.221

Senile purpura

D69.2

48

0.221

Immune thrombocytopenic purpura

D69.3

48

0.221

Thrombocytopenia

D69.6

48

0.221

Morbid obesity

Morbid obesity

E66.01

22

0.273

No HCC weight unless BMI is 40 or greater or there are comorbidities.

Code BMI if known

Z68.41–45

22

0.273

Malnutrition

Protein-calorie malnutrition

E46

21

0.545

Malnutrition requires documentation of objective data (e.g., albumin less than 3.4) or subjective data (wasted appearance).

Cachexia

R64

21

0.545

Chronic lung disease

Smoker's cough

J41.0

111

0.328

Document specifically if possible (smoking history, chest computed tomography results, pulmonary function tests, etc.). *Also code Z99.81, dependent on supplemental oxygen.

Emphysema

J43.X

111

0.328

Chronic obstructive pulmonary disease (COPD), other

J44.X

111

0.328

COPD, unspecified

J44.9

111

0.328

Pulmonary fibrosis

J84.10

112

0.209

Chronic respiratory failure

J96.10*

84

0.302

Inflammatory bowel disease

Crohn's disease

K50.90

35

0.294

Ulcerative colitis

K51.90

35

0.294

Chronic hepatitis

Chronic hepatitis C

B18.2

29

0.165

Chronic hepatitis, unspecified

K73.9

29

0.165

Cirrhosis

Alcoholic cirrhosis

K70.30

28

0.390

Non-alcoholic cirrhosis

K74.60

28

0.390

Esophageal varices, no bleed

I85.00

27

0.962

Portal hypertension

K76.6

27

0.962

Chronic pancreatitis

Chronic pancreatitis

K86.1

34

0.276

Rheumatologic problems

Lupus

M32.9

40

0.423

Sicca syndrome (Sjoren)

M35.00

40

0.423

Rheumatoid arthritis

M06.9

40

0.423

Inflammatory polyarthropathy

M06.4

40

0.423

Polymalgia rheumatica

M35.3

40

0.423

Psychiatric problems

Schizophrenia

F20.9

57

0.608

“Run-of-the-mill” depression/anxiety has no HCC weight. Must document Diagnostic and Statistical Manual of Mental Disorders criteria.

Schizoaffective disorder

F25.9

57

0.608

Major depression, recurrent

F33.9

58

0.395

Bipolar disorder

F31.9

58

0.395

Alcoholism

F10.20

55

0.383

Alcoholism, in remission

F10.21

55

0.383

Drug dependence

F1X.20

55

0.383

Drug dependence, in remission

F1X.21

55

0.383

Neurologic problems

Parkinson's disease

G20

78

0.585

Remember to list these chronic diseases annually, even if primary management is by a consultant.

Multiple sclerosis

G35

77

0.441

Paralysis

G83.9

104

0.395

Seizure disorder

G40.909

79

0.227

Ischemic stroke

Varies

100

0.265

Cardiac disease

Angina

I20.9

88

0.140

Coronary artery disease with angina

I25.119

88

0.140

Unstable angina

I20.0

87

0.218

Acute myocardial infarction

I21.3

86

0.233

Pulmonary hypertension

I27.2

85

0.323

Cor pulmonale

I27.81

85

0.323

Cardiomyopathy

I42.9

85

0.323

CHF

I50.9

85

0.323

Atrial fibrillation

I48.91

96

0.268

Aortic atherosclerosis

I70.0

108

0.298

Abdominal aortic aneurysm

I71.4

108

0.298

Deep venous thrombosis (DVT)

DVT, acute

I82.40

108

0.298

DVT, chronic

I82.50

108

0.298

Vascular disease

Peripheral vascular disease

I73.9

108

0.298

Diabetic peripheral vascular disease

E11.51

18

0.318

Venous stasis ulcers with varicose veins

I83.0

107

0.400

Chronic venous stasis ulcer

I87.31

107

0.400

Ophthalmology

Wet macular degeneration

H35.32

124

0.499

Proliferative diabetic retinopathy

E11.359

18

0.318

Trauma

Concussion w/o loss of consciousness, sequelae

S06.0X0S

167

0.191

Any code reflecting major or severe head trauma has HCC weight.

Head injury with subdural hemorrhage

S06.6X6A

166

0.584

Hip fracture

S72.009A

170

0.418

Artificial openings

Tracheostomy status

Z93.0

82

1.055

Gastrostomy status

Z93.1

188

0.571

Colostomy status

Z93.3

188

0.571

Cystostomy status

Z93.5

188

0.571

Amputation status

Specify site

Z89.4-6

189

0.588

Lower limb only.

Major organ transplant

Heart transplant status

Z94.1

186

1.000

Can be any duration from surgery.

Lung transplant status

Z94.2

186

1.000

Liver transplant status

Z94.4

186

1.000

Excluded chronic conditions

Essential hypertension, hyperthyroidism or hypothyroidism, iron deficiency anemia, gastroesophageal reflux, osteoarthritis, and tobacco use.


1. 2017 midyear final ICD-10 mappings. Centers for Medicare & Medicaid Services (CMS) website. http://go.cms.gov/2ELl0qM. Accessed February 15, 2018.

2. Announcement of calendar year 2017 Medicare capitation rates and Medicare Advantage and Part D payment policies and final call letter. CMS website. http://go.cms.gov/1V577FB. April 2016. Accessed February 15, 2018.

ICD-10 — HCC CODING REFERENCE FOR FAMILY MEDICINE

 Download in PDF format

If your patient has any of these problems, document the diagnosis, assessment, and plan, and report the corresponding code annually.

ExamplesICD-10HCC1HCC weight2Notes

Type 2 diabetes (T2D)

T2D without complications

E11.9

19

0.104

Always has HCC weight. Document as specifically as possible.

T2D with hyperglycemia

E11.65

18

0.318

T2D with hypoglycemia, no coma

E11.649

18

0.318

T2D with mild retinopathy

E11.329

18

0.318

T2D with diabetic chronic kidney disease (CKD)

E11.22

18

0.318

T2D with polyneuropathy

E11.42

18

0.3168

Long term (current) insulin use

Z79.4

19

0.104

Hypertension (HTN)

HTN with congestive heart failure (CHF)

I11.0

85

0.323

Isolated essential HTN has no HCC weight. Relationship must be explicitly documented.

HTN + CKD stage 5/end stage renal disease (ESRD)

I12.0

136

0.237

HTN + CHF + CKD stage 1–4

I13.0

85

0.323

HTN + CHF + CKD stage 5/ESRD

I13.2

85

0.323

HTN + heart disease (no CHF) + CKD 5/ESRD

I13.11

136

0.237

Chronic kidney disease (CKD)

CKD stage 4, glomerular filtration rate (GFR) 15–29

N18.4

137

0.237

No HCC weight unless stage 4 or worse, or associated with HIV.

CKD stage 5, GFR <15

N18.5

136

0.237

ESRD

N18.6

136

0.237

Major infections

HIV/AIDS

B20

1

0.312

Active infections — serious, systemic, opportunistic, or bone/joint/muscle.

Sepsis

A41.8

2

0.455

Cancer

Breast cancer

C50.9

12

0.146

Active cancers — new, under treatment, or treatment declines — with documentation of any metastases.

Prostate cancer

C61

12

0.146

Lung, gastrointestinal, or pancreatic cancers

Varies

9

0.970

Metastasis to lymph nodes

C77.X

8

2.625

Hematologic problems

Myelodysplastic syndrome

D46.9

46

1.388

Aplastic anemia

D61.9

46

1.388

Acquired coagulopathy

D68.4

48

0.221

Senile purpura

D69.2

48

0.221

Immune thrombocytopenic purpura

D69.3

48

0.221

Thrombocytopenia

D69.6

48

0.221

Morbid obesity

Morbid obesity

E66.01

22

0.273

No HCC weight unless BMI is 40 or greater or there are comorbidities.

Code BMI if known

Z68.41–45

22

0.273

Malnutrition

Protein-calorie malnutrition

E46

21

0.545

Malnutrition requires documentation of objective data (e.g., albumin less than 3.4) or subjective data (wasted appearance).

Cachexia

R64

21

0.545

Chronic lung disease

Smoker's cough

J41.0

111

0.328

Document specifically if possible (smoking history, chest computed tomography results, pulmonary function tests, etc.). *Also code Z99.81, dependent on supplemental oxygen.

Emphysema

J43.X

111

0.328

Chronic obstructive pulmonary disease (COPD), other

J44.X

111

0.328

COPD, unspecified

J44.9

111

0.328

Pulmonary fibrosis

J84.10

112

0.209

Chronic respiratory failure

J96.10*

84

0.302

Inflammatory bowel disease

Crohn's disease

K50.90

35

0.294

Ulcerative colitis

K51.90

35

0.294

Chronic hepatitis

Chronic hepatitis C

B18.2

29

0.165

Chronic hepatitis, unspecified

K73.9

29

0.165

Cirrhosis

Alcoholic cirrhosis

K70.30

28

0.390

Non-alcoholic cirrhosis

K74.60

28

0.390

Esophageal varices, no bleed

I85.00

27

0.962

Portal hypertension

K76.6

27

0.962

Chronic pancreatitis

Chronic pancreatitis

K86.1

34

0.276

Rheumatologic problems

Lupus

M32.9

40

0.423

Sicca syndrome (Sjoren)

M35.00

40

0.423

Rheumatoid arthritis

M06.9

40

0.423

Inflammatory polyarthropathy

M06.4

40

0.423

Polymalgia rheumatica

M35.3

40

0.423

Psychiatric problems

Schizophrenia

F20.9

57

0.608

“Run-of-the-mill” depression/anxiety has no HCC weight. Must document Diagnostic and Statistical Manual of Mental Disorders criteria.

Schizoaffective disorder

F25.9

57

0.608

Major depression, recurrent

F33.9

58

0.395

Bipolar disorder

F31.9

58

0.395

Alcoholism

F10.20

55

0.383

Alcoholism, in remission

F10.21

55

0.383

Drug dependence

F1X.20

55

0.383

Drug dependence, in remission

F1X.21

55

0.383

Neurologic problems

Parkinson's disease

G20

78

0.585

Remember to list these chronic diseases annually, even if primary management is by a consultant.

Multiple sclerosis

G35

77

0.441

Paralysis

G83.9

104

0.395

Seizure disorder

G40.909

79

0.227

Ischemic stroke

Varies

100

0.265

Cardiac disease

Angina

I20.9

88

0.140

Coronary artery disease with angina

I25.119

88

0.140

Unstable angina

I20.0

87

0.218

Acute myocardial infarction

I21.3

86

0.233

Pulmonary hypertension

I27.2

85

0.323

Cor pulmonale

I27.81

85

0.323

Cardiomyopathy

I42.9

85

0.323

CHF

I50.9

85

0.323

Atrial fibrillation

I48.91

96

0.268

Aortic atherosclerosis

I70.0

108

0.298

Abdominal aortic aneurysm

I71.4

108

0.298

Deep venous thrombosis (DVT)

DVT, acute

I82.40

108

0.298

DVT, chronic

I82.50

108

0.298

Vascular disease

Peripheral vascular disease

I73.9

108

0.298

Diabetic peripheral vascular disease

E11.51

18

0.318

Venous stasis ulcers with varicose veins

I83.0

107

0.400

Chronic venous stasis ulcer

I87.31

107

0.400

Ophthalmology

Wet macular degeneration

H35.32

124

0.499

Proliferative diabetic retinopathy

E11.359

18

0.318

Trauma

Concussion w/o loss of consciousness, sequelae

S06.0X0S

167

0.191

Any code reflecting major or severe head trauma has HCC weight.

Head injury with subdural hemorrhage

S06.6X6A

166

0.584

Hip fracture

S72.009A

170

0.418

Artificial openings

Tracheostomy status

Z93.0

82

1.055

Gastrostomy status

Z93.1

188

0.571

Colostomy status

Z93.3

188

0.571

Cystostomy status

Z93.5

188

0.571

Amputation status

Specify site

Z89.4-6

189

0.588

Lower limb only.

Major organ transplant

Heart transplant status

Z94.1

186

1.000

Can be any duration from surgery.

Lung transplant status

Z94.2

186

1.000

Liver transplant status

Z94.4

186

1.000

Excluded chronic conditions

Essential hypertension, hyperthyroidism or hypothyroidism, iron deficiency anemia, gastroesophageal reflux, osteoarthritis, and tobacco use.


1. 2017 midyear final ICD-10 mappings. Centers for Medicare & Medicaid Services (CMS) website. http://go.cms.gov/2ELl0qM. Accessed February 15, 2018.

2. Announcement of calendar year 2017 Medicare capitation rates and Medicare Advantage and Part D payment policies and final call letter. CMS website. http://go.cms.gov/1V577FB. April 2016. Accessed February 15, 2018.

ABOUT THE AUTHORS

show all author info

Dr. Belatti is a resident physician at St. Mary's Hospital in Grand Junction, Colo....

Dr. Lykke is a faculty physician at St. Mary's Hospital.

Author disclosures: no relevant financial affiliations disclosed.

 
 

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