HCC Coding Interview Essentials: A Quick
Knowledge Boost
As a passionate HCC Medical Coder, I've compiled some key topics and coding concepts
that often come up during interviews. These essentials not only help in acing the
interview but also reflect a strong foundational understanding of HCC and risk
adjustment coding.
Core Concepts & Acronyms
1. HCC (Hierarchical Condition Category): A risk-adjustment model developed
by CMS to predict future healthcare costs based on a patient’s chronic and serious
diagnoses. It plays a key role in Medicare Advantage and other risk-based
programs.
2. HCPCS (Healthcare Common Procedure Coding System): Used mainly for
hospital supplies, durable medical equipment (DME), and outpatient services. It
complements CPT codes for billing non-physician services.
3. CPT (Current Procedural Terminology): Maintained by the AMA, CPT codes
are used to describe medical, surgical, and diagnostic procedures and services
performed by healthcare professionals.
4. CMS (Centers for Medicare & Medicaid Services): A U.S. federal agency
overseeing Medicare, Medicaid, and the Health Insurance Marketplace. CMS also
governs rules for HCC and risk adjustment coding.
5. Rx HCC (Prescription-based HCC Model): Used in Medicare Part D risk
adjustment. It uses prescription data to support HCC diagnoses, especially under
CMS-HCC V05 model.
Medical Record Components & Standards
1. Key Components of a Medical Record:
– CC (Chief Complaint): The primary reason for the patient's visit.
– HPI (History of Present Illness): A chronological description of the
patient's illness.
– ROS (Review of Systems): A head-to-head inquiry of body systems.
– PE (Physical Examination): The physician's objective findings.
– Assessment & Plan: Clinical impression and treatment strategy.
2. HIPAA (Health Insurance Portability and Accountability Act): Ensures data
privacy and security for protected health information (PHI).
Coding Structures & Guidelines
1. Current vs Past Medical History Headers:
– Current: PE, ROS, Assessment, Plan
– Past: PMH (Past Medical History), Surgical History, Social History
2. ICD-10-CM Structure: A 3-7 character alphanumeric format where letters
indicate category, followed by characters denoting etiology, location, and severity.
3. ‘X’ Placeholder: Used to maintain correct code length when a 7th character is
needed but preceding characters are unavailable.
4. ICD-10 Punctuation & Instructions:
– Excludes 1: Mutually exclusive conditions; cannot be coded together (e.g.,
B20 and Z21).
– Excludes 2: Conditions that can be coded together if supported by
documentation (e.g., J47.9 and J43.9).
– See/See Also: Directs coders to more appropriate terms in the Alphabetic
Index.
5. Etiology vs Manifestation:
– Etiology: Cause of disease.
– Manifestation: Effect/symptom/result. Use "Code first" for etiology and
"Use additional code" for the manifestation.
Condition-Specific Coding
1. Examples of Acute/Critical Conditions: Myocardial Infarction (MI), Deep Vein
Thrombosis (DVT), Pulmonary Embolism, Unstable Angina, Severe Fractures,
Stroke, Sepsis, Acute Renal Failure, Septic Shock, Cardiac Arrest.
2. MEAT Criteria (for validating conditions):
– M – Monitoring
– E – Evaluation
– A – Assessment
– T – Treatment
– TAMPER is an alternative mnemonic (Treatment, Assessment,
Monitoring, Plan, Evaluation, Referral).
3. Common Guidelines for Specific Conditions:
– Fractures: Include laterality, type (open/closed), healing stage, and
encounter type. Use the 7th character (A, D, S) as appropriate.
– Diabetes Mellitus (DM): 5 types (Type 1, Type 2 (default), Drug-induced,
Secondary/Other, Post-pancreatectomy). Always check for combinations
with CKD, neuropathy, or retinopathy.
– Pulmonary Embolism: Life-threatening; code from inpatient records
(discharge summaries, critical care notes).
– Deep Vein Thrombosis (DVT): Critical condition; must have strong
documentation and prompt treatment.
– Chronic Kidney Disease (CKD): Stages 1–4 (N18.1–N18.4), Stage 5–6
(N18.5–N18.6), ESRD (Z99.2). Specific codes for DM+CKD (E11.22 +
CKD stage), CKD+HTN (I12.9/I12.0), CKD+HTN+HF (I13.0 + I50.x +
N18.x).
– Sepsis: Look for clinical evidence (temp, HR, BP, source of infection).
Severe Sepsis: Code underlying infection + R65.20. Septic Shock: Add
R65.21 + T81.12 (if post-procedural). Sequence matters!
– CAD (Coronary Artery Disease): Code based on involvement of angina,
stents, bypass, etc. Combine with I25.10–I25.9 as appropriate.
– DM Combinations: ICD-10 has combination codes for diabetes with
complications (e.g., E11.22 for DM with CKD, E11.40 for DM with
neuropathy). Use the most specific code.
– Ectomy Coding: Derived from surgical history/physical exam findings.
Code the absence of an organ (e.g., Z90 series) and document the reason for
removal.
