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Provider Manual

Risk Adjustment - Cardiovascular conditions

Last Updated on January 24, 2019

Cardiovascular Conditions and Hierarchical Condition Category Coding

There are multiple cardiovascular conditions associated with Hierarchical Condition Category (HCC) codes.  Risk adjustment hierarchies exist between some of these conditions.  This reinforces the importance of clear, specific and accurate documentation and coding at the time of evaluation and management services by providers. Never select a code more descriptive than your documentation!  Condition specific coding details are outlined in this document.

Although there is no specific impact on whether a diagnosis will risk adjust, ICD 10 indicates that codes related to tobacco exposure or use be coded along with the cardiovascular condition code, when known.  Documentation would also need to include this information; 

  • Exposure to tobacco smoke
  • History of tobacco use
  • Occupational exposure to environmental tobacco smoke
  • Tobacco use or dependence

Heart Rhythm Abnormalities

The following rhythm abnormality diagnoses are associated with a HCC in the Medicare Advantage Risk Adjustment model;

  • Atrial fibrillation
  • Atrial flutter
  • Ventricular fibrillation
  • Ventricular flutter
  • Sick sinus syndrome

When documenting on atrial fibrillation and flutter it is helpful to clarify if the rhythm is

  • Paroxysmal
  • Persistent
  • Chronic
  • Typical
  • Atypical
  • Treated – include agent and  response to treatment

Bradycardia, tachycardia and palpitations are not associated with a HCC. 

Atherosclerosis – Documentation should clarify whether the condition

  • Affects a native coronary artery
  • Affects a bypass graft
    • Identify type of bypass
    • Identify type of graft
    • Is associated with angina pectoris (stable/unstable)
    • Is angina associated with documented spasm

Chest pain

  • Unstable angina
  • Angina pectoris with documented spasm
  • Other forms of angina pectoris

Documentation should indicate what is being used to treat angina, and response to treatment, even if the condition is stable.

Acute Myocardial Infarction (MI) –

Documentation should include

  • Date of the MI – acute MI is coded for 4 weeks following the event.  Diagnosis becomes old MI (which does not risk adjust) at 4 weeks 1 day.
  • Type – ST elevation MI vs Non ST elevation MI
  • Location of MI
  • Initial or subsequent event

Hypertension

Hypertension alone is not a HCC.  However, when it is documented as the cause of other conditions, such as chronic kidney disease or heart disease, it may be associated with a HCC diagnosis.  In fact, there may be more than 1 HCC associated with these diagnoses.  For example, Hypertensive heart and chronic kidney disease with diastolic heart failure and stage 4 CKD would add the diagnosis codes and HCC’s noted on the following table;

Diagnosis code HCC code
I 13.0 - Hypertensive heart & CKD with heart failure 85
I50.30 – Unspecified diastolic heart failure 85
N18.4 - Stage 4 CKD ; 137

With transition to ICD 10, the focus of documentation should be on the type of hypertension

  • Primary
  • Secondary – state the cause

Hypertension is no longer identified as benign or malignant in ICD 10.  There are no distinctions for controlled or uncontrolled.

Heart Failure

Document and code the following details related to heart failure

  • Is heart failure due to another condition
    • Hypertension
    • Hypertension with CKD
    • Following surgery
    • Type of heart failure
      • Left ventricular failure
      • Systolic, diastolic or combined systolic and diastolic
      • Acute, chronic, or acute on chronic

Cardiomyopathy

Cardiomyopathy is associated with a HCC code.  Documentation should include the following details in order to select the correct ICD 10 code;

  • Type – dilated, obstructive or nonobstructive hypertrophic, endomyocardial, endocardial fibroelastosis, alcoholic, due to drugs or other agents
  • Location – endocarditis, right ventricle, etc.
  • Cause – congenital, alcohol or other condition
  • List cardiomyopathy seen in other diseases such as gout, amyloidosis, thyrotoxicosis, etc.

Heart Valve Disease

Heart valve disease is not associated with a HCC code in the Medicare Advantage model.  The following information will help you to accurately document and code heart valve disease following ICD 10 coding guidelines.

ICD 10 assumes that heart valve disease is rheumatic; it is important to document otherwise, if this is not the case.  When documenting heart valve diseases include the following details;

  • Cause – Rheumatic or non-rheumatic
  • Affected valve – mitral, aortic, tricuspid, pulmonary
  • Type – insufficiency, prolapse, regurgitation, incompetence, stenosis, etc.

Aneurysms & dissection

Aneurysms and dissections are associated with a HCC code in the Medicare Advantage model.  When documenting and coding about these conditions, be sure to include the following details;

  • Aneurysm or dissection
  • Location – aorta (thoracic, abdominal, thoracoabdominal, carotid artery, renal or iliac artery, or artery of upper or lower extremity)
  • Ruptured or without rupture

Questions

Brenda Anderson
Revenue Management Educator
Security Health Plan 
Telephone: 715-221-9598

Ann Meverden
Revenue Management Educator
Security Health Plan 
Telephone: 715-221-9352

Shared email:   rf.shp.risk.adjustmnt@securityhealth.org