HCC Coding Guidelines Part 5: Chronic Conditions That Must Be Captured

In HCC coding, some conditions stay with the patient for life and continue to affect the cost of care. These are chronic, progressive, or irreversible diseases, and they carry significant HCC weight. Capturing them correctly ensures that risk scores truly reflect the patient’s health status and that providers are reimbursed appropriately for the complexity of care.

Common Chronic Conditions That Impact HCCs

Below is a list of conditions that are generally lifelong and not reversible. Coders must carefully review documentation and apply HCC guidelines when coding them:

• Amyotrophic Lateral Sclerosis (ALS)

• Alzheimer’s Disease

• Amputation Status

• Asbestosis

• Bipolar Disorder

• Crohn’s Disease

• Chronic Kidney Disease (CKD) / Renal Failure

• Chronic Obstructive Pulmonary Disease (COPD) / Chronic Bronchitis / Chronic Asthma

• Cirrhosis of the Liver (unless resolved with transplant)

• Congestive Heart Failure (CHF)

• Diabetes Mellitus (all types)

• Diabetic Proliferative Retinopathy

• Diabetic Neuropathy

• Emphysema

• End Stage Liver Disease (unless resolved with transplant)

• End Stage Renal Disease (unless resolved with transplant)

• HIV/AIDS

• Huntington’s Disease

• Major Organ Transplant Status

• Multiple Myeloma

• Multiple Sclerosis

• Muscular Dystrophy

• Myasthenia Gravis

• Paraplegia

• Parkinson’s Disease

• Pulmonary Fibrosis

• Quadriplegia

• Rheumatoid Arthritis

• Schizophrenia

• Sickle-Cell Disease

• Systemic Lupus Erythematosus (SLE)

These conditions usually do not improve or go away, and therefore, they must be coded every calendar year to ensure the HCC risk adjustment model captures them.

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Important Limitations Coders Must Remember

Not every mention of these conditions should be coded. Coders should avoid overcoding by applying these rules:

1. Contradictory Evidence

If the medical record contains conflicting documentation (for example, one note says “CKD stage 3” and another says “normal kidney function”), the coder should not assign the code until clarification is obtained.

2. “History of” Phrasing

The phrase “history of” can be tricky. If the provider uses “history of diabetes” but clearly means the patient still has diabetes, coders may assign the code. However, if documentation indicates the condition is truly resolved, then a history (Z code) should be used instead, and not an active HCC code.

3. Stand-Alone Problem Lists

If a condition is listed only on a problem list without being addressed in a face-to-face encounter note, it should not be coded as current. Coders must ensure the diagnosis is evaluated, treated, or monitored during the encounter.

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Why It Matters: Revenue Impact

Each of these chronic conditions adds risk weight to a patient’s RAF (Risk Adjustment Factor) score. That score determines reimbursement under Medicare Advantage or ACO models.

• Example 1:
  If a patient has diabetes without complications (E11.9), the HCC weight might add only $1,200 per year in reimbursement.
  If the same patient has diabetes with CKD (E11.22), the HCC weight could rise to $4,500 per year.

• Example 2:
  Failing to code congestive heart failure (I50.9) may cause the plan to lose $3,000–$5,000 in reimbursement for that patient annually.

• Example 3:
  Overcoding — assigning Alzheimer’s disease (G30.9) without clear provider documentation — could trigger audits, repayment demands, and compliance penalties that may cost the organization tens of thousands of dollars.

Accurate coding means the difference between fair payment for complex care and financial losses that can harm providers and health systems.

Key Takeaway:
Chronic, lifelong conditions are the backbone of HCC coding. Coders must capture them consistently and correctly each year, while avoiding errors like coding based only on problem lists or vague “history of” documentation. Correct HCC coding protects both patient care accuracy and provider reimbursement.