Part 1 HCC Coding with ICD-10-CM: Guidelines, MEAT, Chronic & Acute Conditions.

What is HCC?

HCC means Hierarchical Condition Category. It is a model used by CMS (Centers for Medicare & Medicaid Services) to adjust risk and predict future healthcare cost of a patient. Basically, it shows the real health status of a patient based on chronic and some serious acute conditions.

• CMS has around 189 HCC categories.
• Started in 1994, now it is backbone of Medicare Advantage risk adjustment.
• HCCs come from ICD-10-CM codes written by providers.
• Not all ICD-10 codes are HCC, but the ones that are included affect CMS payments and show the true patient condition.

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Medicare Plan Basics

• Part A – Inpatient hospital, SNF, hospice
• Part B – OP visits, preventive care, DME
• Part C – Medicare Advantage (A + B combined)
• Part D – Pharmacy benefits

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Principles of HCC Coding

• Code only if condition is clinically proved in medical record.
• Chronic conditions should be coded every year if doctor is monitoring, evaluating, assessing, or treating (MEAT).
• Capture all conditions that affect patient care and management.
• Link conditions with terms like “due to”, “secondary to”, “associated with”.
• Do not code ruled out, resolved, or only suspected diagnosis.

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MEAT in HCC

For HCC, simple documentation is not enough. We need MEAT support:

• M – Monitor: disease progress, symptoms
• E – Evaluate: tests, results, treatment response
• A – Assess: doctor’s impression, diagnosis
• T – Treat: medicines, therapies, follow-up

 If MEAT is not there, HCC will not count.

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Chronic Conditions Usually Seen in HCC

Condition	Example Code	HCC Impact
CHF	I50.9	HCC 85
Diabetes Mellitus Type 2	E11.9	HCC 18/19
COPD	J44.9	HCC 111
Peripheral Vascular Disease	I73.9	HCC 108
Atrial Fibrillation	I48.91	HCC 96
HIV/AIDS	B20 / Z21	HCC 1
Multiple Sclerosis	G35	HCC 77
Parkinson’s Disease	G20.A1	HCC 81
Lupus (SLE)	M32.9	HCC 75
Rheumatoid Arthritis	M06.9	HCC 40

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Status Codes in ICD-10-CM

Some status codes are also important as they show ongoing patient condition:

• I25.2 – Old MI
• B20 – HIV disease
• Z21 – Asymptomatic HIV
• Z94.- – Transplanted organ/tissue status
• Z89.- – Absence of limb (amputation status)

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Acute Conditions and HCC Coding

Now one big doubt: Do acute conditions come under HCC?

Yes, but only few serious ones. HCC is mainly for chronic problems, but CMS also includes some acute conditions which cost high and need big care.

Examples:

• Acute MI (I21.-) → HCC 86
• Severe Sepsis with shock (A41.- + R65.21) → HCC 2
• Acute respiratory failure (J96.0-) → HCC 82

When to code acute conditions:

• If doctor has confirmed and documented it.
• If it is treated or managed (hospitalization, meds, therapy).
• If proper MEAT is written.

Why important:

• Because conditions like heart attack, sepsis, stroke increase sudden cost.
• CMS wants fair payment, so these are counted.

How to code:

• Use most specific ICD-10-CM code.
• Capture any related complications (e.g., organ failure in sepsis).
• If both chronic and acute are present, code both. Example:
  • I50.9 – Heart failure, unspecified (chronic)
  • I50.21 – Acute systolic heart failure (acute, higher HCC value)

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Final Words

• Chronic conditions must be coded every year with MEAT support.
• Serious acute conditions also adjust risk if properly documented.
• Correct ICD-10-CM coding makes sure patient risk score is true, and hospital/provider get right reimbursement