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Network Matters
News and Information for the
Harvard Pilgrim Health Care Network

July 2018

Hierarchical Condition Categories Coding Reminders


Thorough reporting by physicians is essential to maintaining accurate medical records. When reporting medical care for patients with complex conditions, it is important to emphasize correct documentation and to focus on hierarchical condition categories (HCC) coding.

HCCs are a set of broad conditions (for example, asthma or congestive heart failure) into which diagnosis codes are grouped under Medicare and the Affordable Care Act’s risk adjustment model. The reporting of HCCs must be based on clinical medical record documentation from a face-to-face encounter. HCCs should be captured at least once every 12 months. The standard for how to properly document all active chronic conditions and any conditions that are relevant to a patient’s current care is a set of guidelines known as M.E.A.T:

  • Monitor: signs, symptoms, disease progression, disease regression
  • Evaluate: test results, medication effectiveness, response to treatment
  • Assess/address: ordering tests, discussion, review records, counseling
  • Treat: medications, therapies, and other modalities

Adhering to M.E.A.T. is crucial for a diagnosis to be valid and captured for risk adjustment.

When doing so, remember to:

  • Document all conditions evaluated during each encounter
  • Include a proper progress note with the history of present illness, physical exam, and medical decision-making process
  • Document each diagnosis in an assessment and care plan (do not just list the code)
  • Make sure each diagnosis provides evidence that the provider is monitoring, evaluating, assessing/addressing, and treating the condition (M.E.A.T.)

Please keep in mind that simply cloning diagnoses from previous encounters could trigger an audit and hold up the payment process, so it is important to thoroughly evaluate each condition with each encounter.

Quick takeaway HCC coding tips:

  • Always code to the highest level of specificity
  • Maintain HCCs from a prior health plan if relevant
  • Adhere to M.E.A.T.
  • Capture HCCs at least once a year
  • Use linkage statements for manifestation codes

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