Specialists & HCC Coding

Q: The question is whether or not specialty clinics diagnostic codes count for HCC coding for the patient. We have several patients being followed very closely by a specialist and our primary care providers are being asked to put the HCC coding for those diseases. Does the provider need to list all the codes even if a specialist has entered them and sending them to billing?

A: The HCC diagnosis codes submitted and documented by specialists are accepted by CMS. When the encounter data is submitted to the health plans the specialists data is included in their submission to CMS. There are a few exceptions, such as radiology. When a patient is primarily seeing a specialist it is still a good idea for the PCP to note the condition and that it is being treated by the specialist.

Per the ICD-10 official guidelines for coding and reporting: “Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management. " Plus "all conditions that affect the composite picture of the patient's health need to be recorded at least once per year".

Disclaimer: This guidance is to be used for an easy reference; the ICD-9-CM and ICD-10-CM code books and the Official Guidelines for Coding and Reporting are the authoritative references for accurate and complete coding. This blog may contain references or links to statutes, regulations, or other policy materials. It is not intended to take the place of either the written law or regulations. The information presented herein is for general informational purposes only and is accurate as of the date of publication.

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