HCC Coding: The Problem with Coding from Problem Lists


We recently received a question regarding the use of problem lists to support HCC diagnoses:

My question is regarding the documentation source for Inpatient. “Problem Lists’ are not considered a source to get the documentation, is that correct? Is there a website I can go to find this information to share with my Quality Department and Coding Manager? This is an ongoing debate at our facility and I would finally love to have a resolution.

This is a great question and one I am asked regularly. I often refer my clients to the “Risk Adjustment User Group Questions & Answers” published by CMS. While originally answered in 2008, the instruction has not changed. The question of coding from problem lists is discussed:

Q: Is an undated/unsigned problem list acceptable documentation of a diagnosis if the progress notes refer to the list in the medical record?

A: Plans should use the progress notes as documentation to support the diagnosis instead of the problem list. Problem lists can include any and every type of condition for a person regardless of whether the beneficiary received services for the conditions during the data collection period, and are not acceptable stand-alone documentation.

Let’s review the principles of what documentation is required to allow a coder to code a condition for HCC purposes:

1. HCC rules require FACE-TO-FACE encounters. Coding from a problem list when there is no corresponding face-to-face encounter would not be acceptable.

2. Encounter documentation must reference the diagnosis and achieve MEAT requirements. A problem list alone will not do that. To be complete, documentation for HCC Coding must support the MEAT criteria for each condition:

  • Monitor – signs, symptoms, disease progression, disease regression
  • Evaluate – test results, medication effectiveness, response to treatment
  • Assess/Address – ordering tests, discussion, review records, counseling
  • Treat – medications, therapies, other modalities

3. Pulling a problem list into the encounter’s documentation that does not specifically address each of the conditions on the list to the extent of MEAT will not suffice.

4. A problem list may reflect conditions that are no longer pertinent or active. Pulling that list into the encounter could lead to erroneous coding.

Readers interested in more information are referred to this link.

Postscript: While at the Revenue Integrity Summit this week, I had a nice conversation with a physician leader of a large practice in Florida. His practice is immersed in HCCs. He said he is experiencing rejected HCCs where the diagnosis documentation is not meeting ALL 4 elements of MEAT even though the acronym is Monitoring, Evaluating, Assessing OR Treating the condition. The Medical Record Reviewer Guidance for the RADV auditors is silent on the acronym. Bottom line: The more MEAT elements that are documented for a condition, the better.


Fundamentals of HCC Coding
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About the Author

Rose Dunn
Rose Dunn is the Chief Operating Officer at First Class Solutions, Inc., a healthcare information management leader since 1988. Rose is the author of “The Revenue Integrity Manager’s Guidebook” available from the National Association of Healthcare Revenue Integrity and other books on Coding Management and Auditing from HCPro. She engaged herself in ICD-10 more than 10 years before it was implemented. She is assisting Libman Education in the development of an HCC educational program. Rose holds a BS and MBA from Saint Louis University.

9 thoughts on “HCC Coding: The Problem with Coding from Problem Lists

  1. Jeannine Roy - October 9, 2019 at 3:27 pm

    Rose, I am a certified risk adjustment coder and love reading the information that is posted from you. I have a question relating to inpatient claims and HCC codes. Are the HCC codes submitted on an inpatient claim (UB92) used in the patient’s RAF score. These codes are actually taken from face-to-face visits but are for hospital services only and I wasn’t sure if they would be counted towards the patient’s scoring or if only the providers actual charges (1500) are counted. I can’t find any documentation related to this question and was hoping you could answer my question.

    • Rose Dunn - October 13, 2019 at 12:38 am

      Hi Jeannine,
      Yes, diagnosis codes submitted on the UB04 for hospitals are factored into the algorithm that calculates the RAF for the patient for the year. Diagnoses from Hospital (inpatient and outpatient) services as well as CMS approved physicians and providers are acceptable for the RAF calculation.
      Hope that helps,

      • Jeannine Roy - October 21, 2019 at 11:57 am

        Thanks so much for answering my question.

  2. Maria Guerrero - October 9, 2019 at 4:26 pm

    Do all of the 4 elements of the M.E.A.T criteria have to be applied to a condition/dx for it to be used?

    Thank you,
    Maria Guerrero

    • Rose Dunn - October 13, 2019 at 1:11 am

      Hi Maria,
      Ideally, more than one component will be documented but my understanding it that only one component needs to be addressed.
      Hope this helps,

  3. Elizabeth Squires - October 18, 2019 at 1:11 pm

    Can you use the Problem List for greater specificty of a condition?
    For example if the Assessment and Plan states Congestive Heart Failure (I50.9) and the Problem List states Chronic Diastolic Heart Failure (I50.32), would it be acceptable to use the Chronic Diastolic Heart Failure?
    Thank you,
    Beth Squires

    • Rose Dunn - October 19, 2019 at 8:30 pm

      Hi Elizabeth,
      Unfortunately, the Problem List is not considered a documentation source to support a diagnosis that is submitted on a claim for HCC purposes. It can be an indicator for a RADV auditor to determine whether the condition was long standing/chronic but the auditors may utilize this indication on a case-by-case basis. “Evaluate conditions listed for chronicity and supported in the full medical record, such as history, medications, and final assessment.” (RADV Reviewer Guidance 3/19) In summary, my guidance is that only documentation that is contained within the encounter note prepared during the face-to-face meeting with the CMS approved provider and the patient that supports MEAT will be the safest route to achieving a qualified HCC.
      Thanks for the question,

      • Beth Squires - November 1, 2019 at 1:45 pm

        Thank you for the clarification. I appreciaate it.

  4. Theresa Crowder - October 31, 2019 at 2:41 pm

    Can you use the problem list when coding Primary Care/Internal Medicine? I am talking about chronic conditions that the patient is taking medication for.