Queries to providers for HCC dx's


Local Chapter Officer
Best answers
I would like other HCC coders input.

A provider documents Rheumatoid Arthritis w/positive rheumatoid factor (M05.9) in the A/P.
However in the EHR system the provider puts in the dx of Rheumatoid Arthritis w/rheumatoid factor of multiple sites w/o organ or systems (M05.79). This code does not reflect what the provider documented. Due to trying to capture HCCs would you send back to provider asking for them to be more specific in the A/P to put the verbiage needed to capture the code they want (which I find is leading the provider), or would you code the dx as it is in the A/P.

I have always coded the dx off of what the provider documents, and don't rely on the "codes" the provider chooses (that hang out in a different part of the EHR for that encounter)

I've discussed with another coder who says the reason why to send back to provider is that we are doing concurrent review and need the documentation support for what the providers are trying to code in order to capture the correct HCC.

Any thoughts? Thanks

And how do you tell providers nicely that you change the dx if it's not supported.


True Blue
Beaverton OR
Best answers
If you can query the provider, this would be a good first step. As you correctly state, we should never code off the codes the EHR or provider suggests, but rely solely on actual documentation of the chart. This is also what CMS and other payers will look at when they audit the provider. While we should not lead the provide when we query, perhaps point out the discrepancy of RA documentation. Which one is it? Perhaps also bring up that as a coder your job is to code to the most specific code available and according to documentation. When documentation begins to contradict itself, your job becomes increasingly difficult.

Even with clarification from the provider, remember that while you might have this knowledge on the provider's documentation, a future auditor will not. Since I don't have the complete chart in front of me, and can only deduct from what you are explaining, I would probably go with M05.9, since this is what the provider documented in the A/P. The diagnosis coding itself is often irrelevant, unless further MEAT follows the coding underneath it. Ex.:

-Patient is stable, on Methotrexate, due for labs, follow up in 6 weeks
If all we have is the diagnosis description and no MEAT, I would probably defer back to M05.9 instead. Again, all of this depends on the provider's documentation, since every chart has to stand on its own proverbial legs.

Hope this is helpful!