Medical Risk Adjustment Toolkit

Reference Guide to Select MRA Conditions

The following five MRA conditions are complex and often misdiagnosed, proving challenging for the diagnostic coding and documentation process.

  • Diabetes
  • Congestive Heart Failure
  • Chronic Kidney Disease
  • Depression
  • Hypertension
Diabetes Coding & Documentation Guide

The Center for Medicare and Medicaid Services (CMS) has associated diabetes and several of its disease manifestations with HCC codes. If complications are present, the causal relationship between conditions should be documented, and the conditions diagnosed and coded to the highest degree of specificity possible. ICD-10 identifies approximately 200 codes that indicate diabetes mellitus type I, type II or secondary diabetes mellitus and its manifestations. These 200 codes map to one of the following three HCCs:

  • HCC 17 – Diabetes with Acute Complications
  • HCC 18 – Diabetes with Chronic Complications
  • HCC 19 – Diabetes without Complication
  • HCC 122 – Proliferative Diabetic Retinopathy and Vitreous Hemorrhage

Accurate ICD-10 coding along with complete and accurate patient documentation is required to support submission of any HCC to CMS.

Documentation Tips:

  • Documentation should clearly state the patient has diabetes and describe any complications associated with it. Clearly establishing the causal relationship between the conditions is important when it is the provider’s impression that diabetes has caused one or more complications. Words that are helpful to create this relationship include “due to,” “because of,” “secondary to” or “related to.” Providers may also use the word “diabetic” to show that diabetes is the root cause of
    the manifestation.

Provider Considerations

Diabetes is associated with a risk of complications that may affect one or more of an individual’s organ systems. Documentation and the ICD-10 code submitted by a provider for patient services should reflect the relationship between the condition and severity of disease. Ask the following questions to determine correct coding. Is the diabetes:

  • Type I or Type II
  • Secondary to another condition
  • With or without complications
  • With ketoacidosis
  • With hyperosmolarity
  • With coma
  • With renal manifestations
  • With ophthalmic manifestations
  • With neurological manifestations
  • With peripheral circulatory disorders
  • With other specified manifestations (acute vs. chronic ulcer and location)
  • With unspecified complication

Coding Tips:

  • When a patient has diabetes and a manifestation of other related conditions, those should be coded for the patient (i.e. neuropathy due to diabetes, or chronic kidney disease secondary to diabetes).
Congestive Heart Failure Coding & Documentation Guide

Congestive Heart Failure (CHF) is the condition in which heart disease causes breathlessness and abnormal sodium and water retention, often resulting in edema. The congestion occurs either in the lungs or peripheral circulation or both, depending on whether the heart failure is right sided or general. CHF is progressive and often requires chronic disease management. The most frequently observed clinical manifestations include shortness of breath, edema and weight gain. The HCC associated with CHF includes the following.

  • HCC 85 – Congestive Heart Failure

Documentation Tips:

When documenting heart failure, include the following:

  • Type – systolic, diastolic, etc.
  • Acuity – acute, chronic, etc.
  • Disease status – stable, improved, etc.
  • Treatment plan – medicines, lifestyle changes, etc.

Documentation for CHF should include left-sided heart failure, right-sided heart failure or both, and include either acute heart failure, chronic heart failure or acute on chronic heart failure. If known, link CHF to other associated conditions, i.e. hypertension (HTN) & chronic kidney disease (CKD).

Coding Tips:

  • In ICD-10, the term “congestive” is considered a non-essential term for heart failure. ICD-10 has no code for “congestive” heart failure; the term is included in code I50.9 – heart failure unspecified.
  • When documentation of systolic and/or diastolic heart failure is present, “congestive” is included in the code(s) I50.2 Systolic (congestive) heart failure, I50.3 Diastolic (congestive) heart failure or I50.4 Combined systolic (congestive) and Diastolic (congestive) heart failure.

Provider Considerations:
Ask the following questions to determine correct coding:

1. Was heart failure present on admission (POA)?

2. What type of heart failure is it?

□ Systolic

□ Diastolic

□ Systolic and diastolic

3. What is the acuity of the heart failure?

□ Acute

□ Acute on chronic

□ Chronic

4. Is the heart failure known to be due to an underlying condition?

□ Any causative cardiomyopathy

□ Hypertension

□ Hypertension with chronic kidney disease

□ Acute myocardial infarction this admission or within the last four weeks □ Relationship with chronic renal failure, volume overload, or non-cardiac pulmonary edema □ Due to malfunction of cardiac prosthesis □ Following cardiac surgery □ Secondary to hypertensive heart disease link supported by physician


Chronic Kidney Disease Coding & Documentation Guide

Chronic Kidney Disease (CKD) is a slowly developing condition. A review of a patient’s diagnostic studies, relevant clinical findings and the stage of CKD must be documented for a CKD diagnosis to be coded for HCC classification. The Center for Medicare and Medicaid Services (CMS) has associated approximately 60 ICD-10 codes related to a patient’s renal status to identify five HCC codes. The HCC codes associated with renal status are:

  • HCC 134 – Dependence on Renal Dialysis
  • HCC 135 – Acute Renal Failure
  • HCC 136 – Chronic Kidney Disease (Stage 5)
  • HCC 137 – Chronic Kidney Disease, Severe (Stage 4)
  • HCC 138 – Chronic Kidney Disease, Moderate (Stage 3)

Coding Tips:

Code for severity of CKD by designated stages 1-5 using N17-N19 series.

  • If a patient is receiving dialysis treatment, use code E18.6
  • For patients who have received a kidney transplant, code potential complications from the transplant and any evidence of impaired kidney function.
  • Complications should be coded using T86.1 plus any subcategory conditions that may influence the functionality of the transplanted kidney.
  • Code other potential chronic conditions, such as hypertension, hypertensive heart disease and diabetes mellitus.

Provider Considerations:

Ask the following questions to determine correct coding:

1. Is the condition chronic?
Risk factor scores assigned to conditions are different, based upon the need for ongoing care and complications associated with the condition.

2. What is the cause of the kidney disease?
There are multiple causes of kidney disease. When known, the causative factor should be identified, documented and coded.

3. What is the stage of kidney disease?
The higher the stage of kidney disease the more care the patient is likely to need. When the stage of CKD is not documented, it is coded as unspecified, which is not associated with a risk factor score.

4. Does the patient require dialysis or transplant?


Documentation Tips:

  • To support a diagnosis of CKD, documentation must indicate that the patient has chronic kidney disease and include at least one of the following:
  • Review of diagnostic reports (blood, urine, imaging)
  • Pertinent clinical findings.
  • Stage of CKD
  • Management of CKD.

Documentation related to kidney disease should include any additional or secondary conditions that may be present. Clearly state any causative relationship that exists between the conditions.




Major Depressive Disorder Coding & Documentation Guide

Major depressive disorder or clinical depression is a common but serious mood disorder. Major depressive disorder can be seen in patients who have suffered a depressive episode lasting at least two weeks, as manifested by at least five of the following symptoms: depressed mood, loss of interest or pleasure in most or all activities, insomnia or hypersomnia, change in appetite or weight, psychomotor retardation or agitation, low energy, poor concentration, thoughts of worthlessness or guilt, and recurrent thoughts about death or suicidal ideation. ICD-10 diagnostic codes in this category are based on patients having various levels of depression severity and episodic frequency. Major depressive disorder falls into one HCC mapping:

  • HCC 55 – Major Depressive, Bipolar, and Paranoid Disorders

Documentation Tips:

  • Be specific in terms of severity: Mild, Moderate, Severe.
  • Specify episodes: Single, Recurrent, Remission.

Provider Considerations:
Several evidence-based media tools are effective in screening for depression. The Patient Health Questionnaire (PHQ-9) is a nine-question instrument for patients to complete in a primary care setting to screen for the presence and severity of depression. The results are used to assist providers in making a depression diagnosis and ranking the severity.

Coding Tips:

  • Avoid broad terms and unspecified codes such as “Depression”, F32.9 (ICD 10 CM code).
  • Be thorough in picking up the details in documentation. This can lead to a better understanding of depression and assist with accurate coding.
  • Remember to code out other mood affective disorders, such as, Manic (F30.-) and Bipolar (F31.-).


Hypertension Coding & Documentation Guide

Hypertension (HTN), also known as high blood pressure (HBP), is a common condition in which the blood pressure in the arteries is constantly elevated. The medical guidelines issued by American Heart Association (AHA) define a blood pressure reading above 130 over 90 millimeters of mercury (mmHg) as hypertensive. When left untreated, high blood pressure can lead to co-morbid complications, such as heart failure and chronic kidney disease. Hypertension presumes a relationship between hypertension and either heart involvement and kidney involvement conditions and are often coded as related using the word “with.” These conditions should be coded as related in the absence of provider documentation, unless documentation clearly states conditions are not related. The HCC associated with hypertension include the following:

  • HCC 85 – Congestive Heart Failure
  • HCC 136 – Chronic Kidney Disease (Stage 5)

Documentation Tips:

  • When documenting hypertension, include both the type (essential or secondary), and the causal relationship (renal or pulmonary).
  • Document occurrence of patient tobacco use and elevated blood pressure reading.

Provider Considerations:

1. An additional code is required to identify the type of Congestive Heart Failure Coding from the I50 (HCC-85) series chart.

2. An additional code is required to identify the stage of CKD from the N18 (HCC-136) series chart.

Coding Tips:

  • Code Essential Hypertension as ICD-10 code: I10.
  • Assign a secondary code from heart disease or kidney disease when there is a causal relationship implied in a paper record (“due to hypertension” or “with hypertension”).
  • If the provider specifies a different cause for hypertension other than heart or kidney involvement, the secondary condition would be coded separately and not linked.
  • If the secondary condition is hypertensive chronic kidney disease, there is a presumed relationship between hypertension and chronic kidney disease. Therefore, the only secondary code used indicates CKD stage (stage 1 -5, end stage renal disease).
  • Use additional diagnostic code(s) to identify tobacco use: history of tobacco dependence, tobacco use, exposure to tobacco and tobacco dependence.


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