HCC Coding Interview Essentials: A Quick
Knowledge Boost
Preparing for an HCC (Hierarchical Condition Category) coding interview? This guide
highlights the most important concepts, guidelines, and practical tips you’ll need to ace your
interview and demonstrate strong foundational knowledge in risk adjustment coding.
1. HCC – Hierarchical Condition Category
A risk-adjustment model developed by CMS to predict future healthcare costs.
Primarily used in Medicare Advantage, ACA marketplace, and other risk-based reimbursement
programs.
Each HCC diagnosis maps to a RAF (Risk Adjustment Factor) score, impacting provider and
plan reimbursement.
2. Coding Systems You Must Know
• ICD-10-CM – Used for diagnoses (HCCs are derived from these codes).
• CPT (Current Procedural Terminology) – Maintained by the AMA, used for medical,
surgical, and diagnostic procedures.
• HCPCS (Healthcare Common Procedure Coding System) – Used for supplies, DME,
ambulance, and non-physician services.
3. CMS – Centers for Medicare & Medicaid Services
Governing body for Medicare, Medicaid, and risk adjustment programs.
Publishes official coding guidelines and updates to HCC/RAF models.
4. Medical Record Components to Validate a Diagnosis
• CC – Chief Complaint
• HPI – History of Present Illness
• ROS – Review of Systems
• PE – Physical Exam
• Assessment & Plan – Physician’s clinical impression and treatment strategy.
Tip: Always ensure documentation supports MEAT/TAMPER criteria.
5. MEAT Criteria (Proof of Diagnosis)
• M – Monitoring
• E – Evaluation
• A – Assessment
• T – Treatment
Alternative: TAMPER – Treatment, Assessment, Monitoring, Plan, Evaluation, Referral.
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6. HIPAA
Ensures privacy, confidentiality, and security of PHI (Protected Health Information).
Interview tip: Stress accuracy + compliance in coding, not just productivity.
7. Current vs Past Medical History Documentation
• Current: PE, ROS, Assessment, Plan
• Past: PMH, Past Surgical History, Social History, Family History
8. Common Acute/Critical Conditions Seen in Risk
Adjustment
Myocardial Infarction (MI)
Stroke
Sepsis & Septic Shock
Pulmonary Embolism (PE)
Deep Vein Thrombosis (DVT)
Unstable Angina
Acute Renal Failure
Severe Fractures
Cardiac Arrest
9. RxHCC – Prescription-based HCC Model
Used in Medicare Part D risk adjustment.
Supports HCC diagnoses using drug utilization patterns.
10. ICD-10-CM Structure & Rules
• 3–7 character alphanumeric codes.
• ‘X’ placeholder used when 7th character required but intermediate positions are empty.
• Excludes 1 = cannot be coded together.
• Excludes 2 = can be coded together if documented.
• Etiology vs Manifestation: Code first = underlying cause. Use additional code =
manifestation.
11. Key Coding Guidelines for Specific Conditions
Diabetes Mellitus (DM)
Types: Type 1, Type 2 (default), Drug-induced, Secondary, Post-pancreatectomy.
Always look for combination codes (e.g., E11.22 – Type 2 DM with CKD).
Chronic Kidney Disease (CKD)
N18.1–N18.6 for stages.
ESRD: Z99.2 (on dialysis).
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Combinations:
DM + CKD: E11.22 + CKD stage.
HTN + CKD: I12.x.
HTN + CKD + HF: I13.x + I50.x + N18.x.
Sepsis
Sequence: underlying infection → severe sepsis → septic shock (if documented).
Add T81.12 if post-procedural.
Coronary Artery Disease (CAD)
Specify angina, bypass, stent, grafts.
Example: I25.10 (without angina), I25.110 (with unstable angina).
Fractures
Must capture laterality, open/closed, initial/subsequent encounter, healing stage.
Use 7th character (A, D, S).
12. RAF Score Basics
Each HCC maps to a numerical value → summed to calculate a patient’s RAF score.
Higher RAF = higher predicted cost = higher reimbursement.
RAF resets each year → conditions must be recaptured annually.
13. Common Interview Questions & Hot Topics
• Difference between HCC and RxHCC.
• Examples of chronic conditions that risk adjust (e.g., COPD, CHF, Diabetes with
complications).
• How you validate a diagnosis using MEAT.
• What’s the difference between Excludes 1 vs Excludes 2?
• Handling vague provider documentation (→ Query process).
• Why compliance and accuracy are more important than volume.
14. Extra Pro Interview Tips
• Always mention RAF recapture: Diagnoses must be coded annually to count.
• Stress coding to the highest specificity.
• Know top HCCs: CHF, COPD, CKD, Diabetes with complications, Major depression,
Vascular disease, Cancer, HIV.
• Query when unclear: Coders cannot assume, they must query providers.
• Red flag for interviewers: Never code from lab reports alone; always from provider
documentation.
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🎯 Final Takeaway
For an HCC coding interview, focus on:
Core concepts (HCC, RAF, MEAT).
Compliance & documentation rules.
Common chronic conditions that risk adjust.
Confidence in coding scenarios (DM, CKD, CAD, Sepsis, Fractures).
Being able to explain the “why” behind your coding choices is what will make you stand out as a
strong candidate.
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