Scenario Analysis: This scenario presents a common challenge in risk adjustment coding: accurately identifying and reporting Hierarchical Condition Categories (HCCs) when multiple related diagnoses are documented. The professional challenge lies in discerning the primary reason for the encounter and the most specific, reportable diagnosis that captures the patient’s acuity, while adhering to coding guidelines and payer requirements. Misinterpretation can lead to inaccurate risk scores, impacting reimbursement and potentially leading to compliance issues. Careful judgment is required to balance the physician’s documentation with the precise rules of ICD-10-CM coding for risk adjustment. Correct Approach Analysis: The best professional practice involves reviewing the entire medical record to identify the principal diagnosis or reason for the encounter, and then selecting the most specific ICD-10-CM code that represents the documented condition, ensuring it maps to a valid HCC. This approach prioritizes the physician’s documented intent and the highest level of specificity available. For example, if a physician documents “acute exacerbation of chronic obstructive pulmonary disease due to pneumonia,” the coder must determine if the pneumonia is the primary driver of the exacerbation or if the COPD exacerbation is the main focus. If the documentation supports pneumonia as the acute condition necessitating the encounter, and it is specified as bacterial, the coder would select the appropriate bacterial pneumonia code, which maps to an HCC. This aligns with ICD-10-CM Official Guidelines for Coding and Reporting, which emphasize reporting the condition that occasions the admission or encounter. Furthermore, it adheres to risk adjustment principles by capturing the most severe, reportable condition that impacts the patient’s health status and resource utilization. Incorrect Approaches Analysis: Coding based solely on the first listed diagnosis without considering the full clinical context or specificity fails to capture the true acuity of the patient’s condition and violates the principle of reporting the condition that occasions the encounter. This can lead to underreporting of risk. Reporting a less specific diagnosis when a more specific one is documented and supported by the record is also a failure. For instance, coding “COPD” when “acute exacerbation of COPD due to bacterial pneumonia” is documented and supported would miss the more severe, reportable condition. Similarly, coding only the chronic condition without acknowledging an acute exacerbation or complication that is the primary reason for the visit would be incorrect. Relying on a generic diagnosis when specific details are provided by the physician, such as the type of pneumonia or the cause of exacerbation, is a direct contravention of ICD-10-CM guidelines and the principles of accurate risk adjustment. Professional Reasoning: Professionals should adopt a systematic approach: 1. Thoroughly review the physician’s documentation for the encounter, paying close attention to the chief complaint, history of present illness, assessment, and plan. 2. Identify the principal diagnosis or the condition that led to the encounter. 3. Consult the ICD-10-CM Official Guidelines for Coding and Reporting to determine the correct sequencing and selection of codes, prioritizing specificity. 4. Map the selected ICD-10-CM codes to the appropriate HCCs, ensuring all documented, reportable conditions that meet HCC criteria are captured. 5. If documentation is ambiguous or lacks specificity, query the physician for clarification to ensure accurate coding and risk adjustment.

The scenario presents a common challenge in healthcare coding: balancing the need for accurate risk adjustment with the ethical and regulatory imperative to avoid upcoding or misrepresenting patient conditions. Professional coders must understand that risk adjustment is designed to reflect the health status of a patient population, not to inflate reimbursement. Misinterpreting or manipulating documentation for financial gain can lead to severe penalties, including audits, fines, and exclusion from federal healthcare programs. The core challenge lies in discerning genuine clinical documentation that supports accurate risk adjustment from documentation that might be ambiguous or suggestive of conditions not fully supported by the medical record. The best approach involves a meticulous review of the entire medical record to ensure that any condition coded for risk adjustment is supported by physician documentation, diagnostic test results, and treatment plans. This means verifying that the documented condition is actively managed, evaluated, or treated during the encounter. For example, if a chronic condition is mentioned but not addressed in any way during the visit, it may not be appropriate to code it for risk adjustment purposes for that specific encounter. This aligns with the principles of accurate coding, which requires that all coded diagnoses are supported by the medical record and reflect the patient’s health status at the time of service. This approach upholds regulatory requirements for accurate reporting and ethical coding practices. An approach that focuses solely on the presence of a diagnosis code in the patient’s problem list without verifying physician documentation for the current encounter is professionally unacceptable. This fails to adhere to the fundamental principle that codes must be supported by the medical record for the specific encounter being coded. It risks overstating the patient’s health burden and can lead to inaccurate risk scores and inappropriate reimbursement. Another professionally unacceptable approach is to code conditions based on assumptions or interpretations that are not explicitly stated or clearly implied by the physician’s documentation. Risk adjustment coding requires objective evidence within the medical record. Guessing or inferring conditions not documented by the provider violates ethical coding standards and regulatory guidelines, which mandate that coders report only what is documented. Finally, an approach that prioritizes coding every possible condition mentioned in the patient’s chart, regardless of its relevance to the current encounter or the physician’s documentation, is also flawed. This can lead to the inclusion of conditions that are historical, resolved, or not actively managed, thereby distorting the patient’s true health status for risk adjustment purposes and violating the principles of accurate and ethical coding. Professionals should employ a systematic decision-making process that begins with a thorough review of the physician’s documentation for the encounter. This includes examining the history of present illness, physical examination findings, assessment, and plan. Coders should query the physician for clarification when documentation is ambiguous or incomplete. They must then cross-reference this documentation with established coding guidelines and payer-specific requirements to ensure accurate assignment of risk adjustment codes. Continuous education on regulatory updates and best practices is crucial for maintaining compliance and ethical integrity.

Scenario Analysis: This scenario is professionally challenging because it requires a coder to balance the immediate need for accurate billing with the long-term imperative of maintaining compliance with complex auditing standards. The pressure to resolve discrepancies quickly can lead to shortcuts that compromise the integrity of the audit process and potentially expose the organization to regulatory penalties. Careful judgment is required to ensure that corrective actions are both effective and compliant. Correct Approach Analysis: The best professional practice involves a systematic review of the audit findings, cross-referencing the identified discrepancies with the original medical record documentation and the applicable coding guidelines. This approach ensures that any identified errors are accurately understood in their context, allowing for precise correction and the identification of root causes. Regulatory compliance, particularly under frameworks like the Centers for Medicare & Medicaid Services (CMS) guidelines for risk adjustment, mandates that all coding and billing decisions be supported by verifiable documentation. This thorough review process directly addresses this requirement by confirming the accuracy of the original coding and justifying any necessary adjustments based on the documented clinical evidence. It also lays the groundwork for identifying systemic issues that may require broader training or process improvements. Incorrect Approaches Analysis: One incorrect approach involves immediately correcting all identified discrepancies based solely on the auditor’s findings without independent verification against the medical record. This fails to uphold the principle that coding decisions must be directly supported by documentation. It bypasses the essential step of ensuring the auditor’s interpretation aligns with the clinical reality and the coder’s original rationale, potentially leading to the introduction of new errors or the masking of underlying documentation deficiencies. Another unacceptable approach is to dismiss the audit findings entirely if the initial coder believes their original coding was correct, without undertaking a detailed review of the auditor’s rationale and the supporting documentation. This demonstrates a lack of professional diligence and a disregard for the established audit process, which is designed to identify potential compliance issues. It ignores the possibility that the auditor may have identified a valid discrepancy or a nuanced interpretation of the documentation that the original coder overlooked. A further incorrect approach is to focus solely on correcting the financial impact of the discrepancies without investigating the underlying reasons for the errors. This approach prioritizes immediate financial resolution over long-term compliance and process improvement. It fails to address the root causes of coding inaccuracies, making it likely that similar errors will recur, thus perpetuating a cycle of non-compliance and increasing the risk of future audit failures and penalties. Professional Reasoning: Professionals should approach audit findings with a commitment to accuracy and compliance. The decision-making process should begin with a thorough understanding of the audit report, followed by a meticulous review of the source documentation and relevant coding guidelines. If discrepancies are confirmed, the focus should be on accurate correction and the identification of root causes. If disagreements arise, they should be addressed through a structured appeals process that relies on objective evidence and established standards. The ultimate goal is to ensure the integrity of the coding and billing process, protect the organization from regulatory risk, and maintain the highest ethical standards.

Scenario Analysis: This scenario presents a common challenge in ICD-10-CM coding where a patient has a condition that is documented but not definitively diagnosed, and the coder must determine the appropriate level of specificity. The professional challenge lies in balancing the need for accurate and complete coding for risk adjustment purposes with the ethical and regulatory imperative to code only what is documented and supported by the medical record. Misinterpreting or overstepping the documentation can lead to inaccurate risk scores, impacting healthcare reimbursements and potentially patient care assessments. Careful judgment is required to adhere strictly to coding guidelines and provider documentation. Correct Approach Analysis: The best professional practice involves assigning the ICD-10-CM code for the condition as documented, without making assumptions about a more specific diagnosis. This means coding the condition as “unspecified” if the provider has not provided further detail. This approach aligns directly with ICD-10-CM Official Guidelines for Coding and Reporting, which emphasize coding to the highest level of specificity documented in the medical record. When a provider documents a condition without further elaboration, the coder must reflect that lack of specificity in the code assignment. This ensures the code accurately represents the provider’s assessment at the time of service and avoids introducing unsupported clinical information. Incorrect Approaches Analysis: Assigning a code for a more specific diagnosis than what is documented by the provider is a significant failure. This violates the fundamental principle of coding based on provider documentation. It introduces unsupported clinical information into the patient’s record, which can lead to inaccurate risk adjustment, incorrect quality measure reporting, and potentially inappropriate clinical decision-making based on flawed data. This approach also breaches ethical coding standards by misrepresenting the patient’s condition. Another incorrect approach is to query the provider for clarification when the documentation is clear about the lack of specificity, even if the coder desires more detail. While querying is essential when documentation is ambiguous or conflicting, it is not appropriate when the provider has intentionally documented a condition as unspecified. Querying in such a situation can be seen as pressuring the provider to change their documentation to meet coding expectations, rather than accurately reflecting the existing record. This can undermine the provider-coder relationship and introduce bias. Finally, assigning a code for a related but different condition that is not explicitly documented is also professionally unacceptable. This is a direct misinterpretation of the documentation and introduces entirely new, unsupported diagnoses. It is a clear violation of coding guidelines and ethical practice, leading to severe inaccuracies in coding and risk adjustment. Professional Reasoning: Professionals should approach this situation by first thoroughly reviewing the provider’s documentation. They must identify the specific condition being addressed and assess the level of detail provided. If the documentation clearly indicates an unspecified condition, the coder should assign the corresponding unspecified ICD-10-CM code. If the documentation is ambiguous, conflicting, or appears to contain an error, the coder should then consider querying the provider for clarification. The decision to query should be based on the need to accurately reflect the patient’s condition as documented, not on a desire for more specific coding information that is not present. Adherence to the ICD-10-CM Official Guidelines for Coding and Reporting is paramount, ensuring that all coding decisions are supported by the medical record and reflect the provider’s clinical judgment.

Scenario Analysis: This scenario presents a common challenge in risk adjustment coding where multiple CPT codes might describe aspects of a patient encounter, but only one can be selected as the primary diagnosis for risk adjustment purposes. The professional challenge lies in accurately identifying the principal diagnosis that drove the patient’s encounter and most significantly impacts their health status for risk adjustment calculations, while also ensuring compliance with coding guidelines and payer policies. Misinterpreting the principal diagnosis can lead to inaccurate risk scores, impacting healthcare reimbursements and potentially misrepresenting the patient’s acuity. Correct Approach Analysis: The best professional approach involves a thorough review of the entire medical record, including physician documentation, progress notes, and any diagnostic test results. The coder must identify the condition that, after study and evaluation, was determined to be the reason for the encounter. This aligns with the fundamental principles of ICD-10-CM coding guidelines, which emphasize coding the condition chiefly responsible for the patient’s admission or encounter. For risk adjustment, this principal diagnosis is critical as it directly influences the Hierarchical Condition Category (HCC) assignment and subsequent risk score. The selected CPT code must accurately reflect the services provided for this principal diagnosis. Incorrect Approaches Analysis: One incorrect approach is to select the CPT code for the condition that is most severe or complex, even if it was not the primary reason for the patient’s visit. This fails to adhere to the principle of coding the condition chiefly responsible for the encounter, potentially leading to an inflated risk score if the more severe condition was a chronic issue managed during a visit for an acute problem. Another incorrect approach is to choose the CPT code that represents the most frequently performed service during the visit, irrespective of the underlying diagnosis. This disregards the diagnostic focus of risk adjustment and prioritizes procedural volume over the patient’s health status, violating coding guidelines and the purpose of risk adjustment. A further incorrect approach is to select the CPT code based solely on the physician’s initial impression without considering the final diagnosis established after evaluation. This can lead to coding based on preliminary assumptions rather than the definitive medical necessity for the encounter, resulting in inaccurate risk adjustment. Professional Reasoning: Professionals should adopt a systematic approach: first, understand the patient’s chief complaint and the reason for the encounter as documented by the physician. Second, review all supporting documentation to confirm the principal diagnosis. Third, select the CPT code that accurately represents the services rendered for that principal diagnosis. Finally, ensure adherence to all relevant coding guidelines and payer-specific policies for risk adjustment.

The scenario presents a common challenge in risk adjustment: ensuring accurate data submission that reflects patient health status while adhering to CMS guidelines. The professional challenge lies in balancing the coder’s responsibility to accurately represent diagnoses with the payer’s incentive to potentially influence coding for financial gain, and the overarching CMS mandate for data integrity. Careful judgment is required to navigate these competing pressures and uphold ethical coding practices. The approach that represents best professional practice involves diligently reviewing all available medical documentation, including physician notes, test results, and specialist reports, to identify all conditions that meet the specificity requirements for risk adjustment reporting. This approach prioritizes accurate and complete coding based solely on documented evidence, aligning with CMS’s emphasis on data integrity and the Hierarchical Condition Category (HCC) model’s purpose of reflecting true patient morbidity. This is correct because CMS requires that all reported diagnoses be supported by physician documentation and meet specific coding guidelines. Adhering strictly to this principle ensures that the risk score accurately reflects the patient’s health status, which is the fundamental goal of the risk adjustment program. It also mitigates the risk of inaccurate reporting, which can lead to financial penalties and erode trust in the program. An incorrect approach involves accepting a payer’s suggestion to add a diagnosis that is not fully documented in the medical record, even if the payer claims it is a common condition for the patient’s demographic. This is ethically and regulatorily flawed because it bypasses the requirement for physician documentation, which is the cornerstone of accurate coding. It also introduces bias into the coding process, potentially inflating the risk score for financial gain, which is a direct violation of CMS program integrity rules. Another incorrect approach is to limit coding to only those diagnoses explicitly mentioned in the physician’s chief complaint or initial assessment, ignoring supporting documentation from other parts of the medical record. This is incorrect because it fails to capture the full spectrum of the patient’s health conditions as documented by the physician and other qualified healthcare professionals. CMS expects coders to perform a comprehensive review of the entire medical record to identify all reportable conditions, not just those highlighted in the initial encounter notes. This approach leads to underreporting of conditions and an inaccurate risk score. A further incorrect approach is to prioritize coding only those diagnoses that are known to be high-value HCCs, regardless of the completeness of the supporting documentation. This is a significant ethical and regulatory failure. It demonstrates a focus on financial incentives over accurate representation of patient health. CMS explicitly prohibits coding practices that are designed to maximize HCC capture without regard for proper documentation and coding guidelines. This approach undermines the integrity of the risk adjustment system and can lead to severe penalties. Professionals should employ a decision-making framework that begins with a thorough understanding of CMS guidelines and the specific requirements for risk adjustment coding. This involves a commitment to data integrity and patient-centered care. When faced with ambiguity or pressure, coders should always refer back to the official coding guidelines and the provider documentation. If clarification is needed, the appropriate professional step is to query the physician for more specific documentation, rather than making assumptions or accepting external suggestions that lack documented support. This systematic approach ensures compliance, accuracy, and ethical practice.

Scenario Analysis: This scenario is professionally challenging because it requires the coder to reconcile potentially conflicting information from different sources within the patient’s medical record. Accurate coding relies on precise anatomical and physiological understanding to interpret physician documentation, especially when descriptions might be ambiguous or incomplete. The risk adjustment coder must ensure that the documented conditions are accurately reflected in the code set, impacting both patient care assessment and financial reimbursement. Careful judgment is required to avoid under- or over-coding, which can have significant consequences. Correct Approach Analysis: The best professional practice involves a thorough review of the entire medical record, prioritizing physician-documented diagnoses and their supporting anatomical and physiological details. This approach ensures that the coder is basing their code selection on the most authoritative information available, directly from the clinician responsible for the patient’s care. When anatomical descriptions are present, the coder must use their knowledge of anatomy and physiology to correctly interpret these descriptions and link them to the appropriate ICD-10-CM codes. For instance, if a physician documents “inflammation of the inner lining of the stomach,” the coder, using their anatomical knowledge, would understand this refers to gastritis and would then seek the specific diagnosis of gastritis in the record. This meticulous cross-referencing and interpretation of anatomical context is crucial for accurate risk adjustment coding. Incorrect Approaches Analysis: One incorrect approach involves solely relying on the patient’s chief complaint or a single note without considering the full clinical picture. This fails to capture the comprehensive nature of the patient’s conditions and the specific anatomical or physiological details that may be documented elsewhere in the record, leading to incomplete or inaccurate coding. Another incorrect approach is to make assumptions about anatomical structures or physiological processes based on common conditions without explicit physician documentation. This violates the principle of coding only what is documented and supported by the record, potentially leading to the assignment of codes that are not medically justified. A further incorrect approach is to code based on external resources or general medical knowledge without direct support from the patient’s medical record. While external resources can aid understanding, the final coding decision must be grounded in the specific documentation provided by the treating physician. Professional Reasoning: Professionals should adopt a systematic approach. First, identify the primary reason for the encounter and any documented diagnoses. Second, meticulously review all physician documentation, paying close attention to any anatomical or physiological descriptions provided. Third, cross-reference these descriptions with the patient’s medical history and other clinical findings within the record. Fourth, utilize knowledge of anatomy and physiology to accurately interpret the documented information and select the most specific and appropriate ICD-10-CM codes. If documentation is unclear or conflicting, query the physician for clarification.

This scenario presents a common challenge in risk adjustment coding: accurately reflecting the patient’s chronic conditions based on the provided documentation, while adhering to specific coding guidelines and payer requirements. The professional challenge lies in interpreting physician documentation that may be ambiguous or incomplete, and ensuring that all documented chronic conditions that impact patient care are captured for accurate risk adjustment, without over-coding or under-coding. Careful judgment is required to balance the need for comprehensive coding with the principle of coding only what is supported by the medical record. The correct approach involves a thorough review of the entire medical record, including physician notes, diagnostic test results, and treatment plans, to identify all documented chronic conditions. This approach prioritizes obtaining clarification from the physician when documentation is unclear or insufficient to assign a definitive code. Specifically, it involves querying the physician to confirm the presence and specificity of conditions like diabetes and hypertension, especially when the documentation suggests these conditions are being managed or treated, or when they impact the patient’s current care plan. This aligns with the principle of coding based on documented evidence and the need for specificity in risk adjustment coding, as outlined by official coding guidelines and payer policies, which emphasize accurate representation of the patient’s health status. An incorrect approach would be to code only the conditions explicitly stated in the physician’s assessment or problem list without considering other parts of the record or seeking clarification. This fails to capture the full scope of the patient’s chronic conditions that may be evidenced elsewhere in the chart, leading to under-reporting of risk. Another incorrect approach is to assume the presence of a chronic condition based on medication lists alone, without explicit physician documentation linking the medication to a diagnosed condition. This violates the principle of coding only documented diagnoses and can lead to inaccurate risk scores. Finally, coding a condition at a less specific level than supported by the documentation, or coding a condition that is mentioned but not actively managed or treated during the encounter, also represents an incorrect approach. This can lead to inaccurate risk adjustment and potential compliance issues. Professionals should employ a systematic decision-making process that begins with a comprehensive review of all available documentation. When ambiguity or insufficiency is identified, the primary step should be to seek clarification from the physician. This iterative process of review, query, and accurate coding ensures that the patient’s health status is accurately reflected for risk adjustment purposes, adhering to both coding ethics and regulatory requirements.

Scenario Analysis: This scenario is professionally challenging because it requires the coder to accurately interpret complex medical terminology within the context of risk adjustment. Misinterpreting terms can lead to incorrect risk scores, impacting healthcare reimbursements and potentially misrepresenting patient acuity. The pressure to be efficient must be balanced with the absolute necessity for precision in medical coding, especially when dealing with terms that have subtle but significant differences in meaning. Correct Approach Analysis: The best professional practice involves meticulously researching the precise definition of “dyspnea” and its specific clinical manifestations as documented by the physician. This approach is correct because accurate coding in risk adjustment relies on a thorough understanding of medical terminology and its direct correlation to documented conditions. The Centers for Medicare & Medicaid Services (CMS) guidelines, which govern risk adjustment, emphasize the importance of coding based on physician documentation and established medical definitions. By cross-referencing the documented term with authoritative medical dictionaries and coding guidelines, the coder ensures that the selected ICD-10-CM code accurately reflects the patient’s condition, thereby correctly influencing the Hierarchical Condition Category (HCC) assignment and the overall risk score. This adheres to the ethical obligation of providing accurate and truthful coding. Incorrect Approaches Analysis: Using a general understanding of “shortness of breath” without confirming the specific medical term documented by the physician is professionally unacceptable. This approach risks misinterpreting the physician’s intent, as “shortness of breath” can encompass a wider range of conditions than the specific medical term “dyspnea” might imply in a risk adjustment context. It fails to adhere to the principle of coding based on specific documentation, which is a cornerstone of risk adjustment accuracy and regulatory compliance. Assuming “dyspnea” is synonymous with a more severe condition like “respiratory failure” without explicit physician documentation is also professionally unacceptable. This overcoding can inflate the risk score inaccurately, leading to improper reimbursement and potentially violating CMS regulations against upcoding. It demonstrates a lack of adherence to the principle of coding only what is documented and supported by the medical record. Selecting a code for “dyspnea” based solely on the presence of other respiratory symptoms without the explicit documentation of “dyspnea” itself is professionally unacceptable. Risk adjustment coding requires a direct link between the documented term and the code assigned. Inferring a diagnosis or symptom without explicit physician documentation is a violation of coding guidelines and ethical practice, as it introduces assumptions rather than relying on factual record-keeping. Professional Reasoning: Professionals should employ a systematic approach when encountering medical terminology in risk adjustment coding. This involves: 1) Identifying the specific medical term documented by the physician. 2) Consulting authoritative medical dictionaries and coding resources (e.g., ICD-10-CM Official Guidelines for Coding and Reporting) to understand the precise definition and clinical implications of the term. 3) Cross-referencing the documented term with the physician’s overall clinical assessment and other supporting documentation in the patient’s record. 4) Selecting the ICD-10-CM code that most accurately and specifically reflects the documented condition, ensuring it aligns with risk adjustment principles and guidelines. If ambiguity exists, seeking clarification from the physician is paramount.

The scenario presents a common challenge in risk adjustment coding: accurately capturing the severity of a patient’s conditions to reflect their health status for payment purposes, while adhering to coding guidelines and payer policies. The professional challenge lies in discerning when a condition, even if documented, meets the criteria for HCC assignment and when it is considered stable or not impacting the current encounter’s medical necessity. Careful judgment is required to avoid both undercoding (which misrepresents patient complexity and impacts payment) and overcoding (which is fraudulent). The best professional approach involves a thorough review of the entire medical record, including physician documentation, diagnostic test results, and treatment plans, to identify conditions that are actively managed, evaluated, or treated during the encounter. This approach prioritizes the principle of “medical necessity” and “significantly affecting the patient’s care.” Specifically, it requires identifying conditions that are documented, evaluated, and treated or monitored, and then mapping these to the appropriate HCC based on official coding guidelines. This ensures that the patient’s risk profile accurately reflects their current health status as supported by comprehensive documentation, aligning with the intent of risk adjustment programs to capture the true cost of care for individuals with chronic conditions. An incorrect approach involves coding an HCC based solely on a physician’s diagnosis without verifying if the condition was actively managed, evaluated, or treated during the encounter. This fails to adhere to the principle that HCCs should reflect conditions that impact the current care provided. Another incorrect approach is to assume that any chronic condition listed in the patient’s problem list automatically qualifies for HCC assignment without specific documentation of its management in the current encounter. This ignores the requirement for active management or evaluation. Finally, an incorrect approach would be to code an HCC based on a condition that is explicitly stated by the physician as resolved or not impacting the current encounter, as this directly contradicts the documentation and the purpose of risk adjustment. Professionals should employ a decision-making framework that begins with a comprehensive review of the encounter documentation. They must then cross-reference this documentation with the official ICD-10-CM coding guidelines and the specific HCC mapping files relevant to the payer. The key is to ask: “Was this condition evaluated, treated, monitored, or does it significantly affect the patient’s current care?” If the answer is yes, and the condition maps to an HCC, then it should be coded. If not, it should not be coded for risk adjustment purposes.