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

Fam Pract Manag. 2018;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, physicians can ensure that their diagnosis 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.”)


  • 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.

ExamplesICD-10HCC1 HCC weight2 Notes
Type 2 diabetes (T2D)
T2D without complicationsE11.9190.104Always has HCC weight.
Document as specifically as possible.
T2D with hyperglycemiaE11.65180.318
T2D with hypoglycemia, no comaE11.649180.318
T2D with mild retinopathyE11.329180.318
T2D with diabetic chronic kidney disease (CKD)E11.22180.318
T2D with polyneuropathyE11.42180.3168
Long term (current) insulin useZ79.4190.104
Hypertension (HTN)
HTN with congestive heart failure (CHF)I11.0850.323Isolated essential HTN has no HCC weight.
Relationship must be explicitly documented.
HTN + CKD stage 5/end stage renal disease (ESRD)I12.01360.237
HTN + CHF + CKD stage 1–4I13.0850.323
HTN + CHF + CKD stage 5/ESRDI13.2850.323
HTN + heart disease (no CHF) + CKD 5/ESRDI13.111360.237
Chronic kidney disease (CKD)
CKD stage 4, glomerular filtration rate (GFR) 15–29N18.41370.237No HCC weight unless stage 4 or worse, or associated with HIV.
CKD stage 5, GFR <15N18.51360.237
Major infections
HIV/AIDSB2010.312Active infections — serious, systemic, opportunistic, or bone/joint/muscle.
Breast cancerC50.9120.146Active cancers — new, under treatment, or treatment declines — with documentation of any metastases.
Prostate cancerC61120.146
Lung, gastrointestinal, or pancreatic cancersVaries90.970
Metastasis to lymph nodesC77.X82.625
Hematologic problems
Myelodysplastic syndromeD46.9461.388
Aplastic anemiaD61.9461.388
Acquired coagulopathyD68.4480.221
Senile purpuraD69.2480.221
Immune thrombocytopenic purpuraD69.3480.221
Morbid obesity
Morbid obesityE66.01220.273No HCC weight unless BMI is 40 or greater or there are comorbidities.
Code BMI if knownZ68.41–45220.273
Protein-calorie malnutritionE46210.545Malnutrition requires documentation of objective data (e.g., albumin less than 3.4) or subjective data (wasted appearance).
Chronic lung disease
Smoker's coughJ41.01110.328Document specifically if possible (smoking history, chest computed tomography results, pulmonary function tests, etc.).
*Also code Z99.81, dependent on supplemental oxygen.
Chronic obstructive pulmonary disease (COPD), otherJ44.X1110.328
COPD, unspecifiedJ44.91110.328
Pulmonary fibrosisJ84.101120.209
Chronic respiratory failureJ96.10*840.302
Inflammatory bowel disease
Crohn's diseaseK50.90350.294
Ulcerative colitisK51.90350.294
Chronic hepatitis
Chronic hepatitis CB18.2290.165
Chronic hepatitis, unspecifiedK73.9290.165
Alcoholic cirrhosisK70.30280.390
Non-alcoholic cirrhosisK74.60280.390
Esophageal varices, no bleedI85.00270.962
Portal hypertensionK76.6270.962
Chronic pancreatitis
Chronic pancreatitisK86.1340.276
Rheumatologic problems
Sicca syndrome (Sjoren)M35.00400.423
Rheumatoid arthritisM06.9400.423
Inflammatory polyarthropathyM06.4400.423
Polymalgia rheumaticaM35.3400.423
Psychiatric problems
SchizophreniaF20.9570.608“Run-of-the-mill” depression/anxiety has no HCC weight.
Must document Diagnostic and Statistical Manual of Mental Disorders criteria.
Schizoaffective disorderF25.9570.608
Major depression, recurrentF33.9580.395
Bipolar disorderF31.9580.395
Alcoholism, in remissionF10.21550.383
Drug dependenceF1X.20550.383
Drug dependence, in remissionF1X.21550.383
Neurologic problems
Parkinson's diseaseG20780.585Remember to list these chronic diseases annually, even if primary management is by a consultant.
Multiple sclerosisG35770.441
Seizure disorderG40.909790.227
Ischemic strokeVaries1000.265
Cardiac disease
Coronary artery disease with anginaI25.119880.140
Unstable anginaI20.0870.218
Acute myocardial infarctionI21.3860.233
Pulmonary hypertensionI27.2850.323
Cor pulmonaleI27.81850.323
Atrial fibrillationI48.91960.268
Aortic atherosclerosisI70.01080.298
Abdominal aortic aneurysmI71.41080.298
Deep venous thrombosis (DVT)
DVT, acuteI82.401080.298
DVT, chronicI82.501080.298
Vascular disease
Peripheral vascular diseaseI73.91080.298
Diabetic peripheral vascular diseaseE11.51180.318
Venous stasis ulcers with varicose veinsI83.01070.400
Chronic venous stasis ulcerI87.311070.400
Wet macular degenerationH35.321240.499
Proliferative diabetic retinopathyE11.359180.318
Concussion w/o loss of consciousness, sequelaeS06.0X0S1670.191Any code reflecting major or severe head trauma has HCC weight.
Head injury with subdural hemorrhageS06.6X6A1660.584
Hip fractureS72.009A1700.418
Artificial openings
Tracheostomy statusZ93.0821.055
Gastrostomy statusZ93.11880.571
Colostomy statusZ93.31880.571
Cystostomy statusZ93.51880.571
Amputation status
Specify siteZ89.4-61890.588Lower limb only.
Major organ transplant
Heart transplant statusZ94.11861.000Can be any duration from surgery.
Lung transplant statusZ94.21861.000
Liver transplant statusZ94.41861.000
Excluded chronic conditions
Essential hypertension, hyperthyroidism or hypothyroidism, iron deficiency anemia, gastroesophageal reflux, osteoarthritis, and tobacco use.

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