The “with” Convention
When indexing codes within the ICD-10-CM there are certain conditions of chronic nature that carry an assumed link to other conditions. In risk adjustment the focus is on those chronic conditions that map to an HCC and when abstracting these codes that assumption tells us that unless the provider specifies otherwise if these conditions are listed together in a patient’s medical chart that they are linked to one another in the absence of etiology. Take notice when indexing these chronic conditions, the term “with” is listed beneath along with a list of conditions and combination codes, this indicates the following conditions have an assumed link to the condition above the “with” term.
MEAT Criteria and Causal Relationship Coding: Navigating the Dilemma
The rigorous application of the MEAT (Monitor, Evaluate, Assess, Treat) criteria presents a unique challenge when coding for causal relationships between diagnoses. Specifically, it raises the question: What level of MEAT documentation is necessary to establish and abstract causal links? When considering a causal relationship where one diagnosis serves as the etiology and another as the manifestation is it required that each diagnosis independently satisfy the MEAT criteria to support coding of both?
In the absence of explicit guidance from authoritative sources such as the ICD-10-CM Official Guidelines, the AHA Coding Clinic, or direct risk adjustment instructions from CMS, coding practices can vary widely. Some organizations will accept the causal relationship if documentation adequately supports at least one of the diagnoses, effectively allowing the link to stand. Others take a stricter approach, insisting that both the etiology and manifestation diagnoses demonstrate sufficient MEAT criteria in the medical record. If one of the diagnoses lacks adequate support, these organizations will not code the causal relationship, and the linkage is considered unsupported.
Best Practices and The Hierarchy
- Member Match: Each encounter must clearly identify the correct patient by name, date of birth, and health plan ID. This ensures the documented diagnoses are linked to the correct member record.
- Date of Service (DOS): The encounter note must specify the exact date of service. This establishes when the provider evaluated and managed the conditions and supports claim submission.
- Face-to-Face Encounter: Documentation must reflect that the provider personally evaluated the patient. Evidence of this includes the physical exam, vital signs, and observed patient appearance.
Chart Components in Hierarchical Order:
- Assessment and Plan (A/P):
The physician’s medical decision making (MDM), including the assessment of each diagnosis and the plan of care. This section should link chronic and acute conditions to treatment, monitoring, or follow-up, ensuring clinical relevance for risk adjustment. - Surgical and Social History:
Documentation of prior surgical procedures and social factors such as smoking, alcohol use, occupation, or social determinants of health. These details establish risk factors and help explain the complexity of the patient’s condition. - Subjective (HPI, ROS, CC):
- History of Present Illness (HPI): Chronological description of the patient’s present illness from first symptom/sign to the current encounter.
- Review of Systems (ROS): Inventory of body systems obtained through patient responses, identifying signs and/or symptoms.
- Chief Complaint (CC): Required for all encounters. Concise statement describing the reason for the visit in the patient’s own words or the physician’s recommended follow-up.
- Objective (Physical Exam & Vitals):
- Physical Exam (PE): Provider’s direct findings based on inspection, palpation, auscultation, or percussion. This supports the face-to-face requirement.
- Vital Signs: Temperature, pulse, respiration, blood pressure, oxygen saturation, height, weight, and BMI. These objective data points further confirm the provider’s evaluation of the patient in real time.
- Problem List:
CMS explains that while the term problem list is commonly used in ambulatory medical record documentation, there is no single universal definition. In practice, the problem list provides coders with a broad clinical overview of a patient’s conditions. It is typically supported by other forms of documentation, including SOAP (subjective, objective, assessment, plan) notes, progress notes, consultation notes, and diagnostic reports. Unlike progress or treatment notes, the problem list functions as a separate menu item that tracks a patient’s injuries, illnesses, and other health-related factors. It serves as a critical communication tool, ensuring that all providers involved in a patient’s care have easy access to the patient’s health history. For physicians, the problem list offers a quick reference to chronic conditions and prior health issues before each encounter. In healthcare facilities, it is especially important for supporting coordinated, comprehensive care by multiple providers. - Past Medical History (PMH):
This includes the patient’s personal history of illnesses, surgeries, injuries, and treatments; a review of family medical history for hereditary conditions or risk factors; and an age-appropriate review of lifestyle factors, past and current activities, and social influences on health.
Now that we have reviewed some of the key foundations for documentation and coding in risk adjustment such as member match, date of service, face-to-face requirements, and the proper chart hierarchy let’s take a closer look at how these principles apply in practice. One of the most common and clinically significant examples is hypertension with heart failure, which requires accurate linkage of conditions to capture the correct HCC category. Below is a table outlining the ICD-10-CM codes for hypertension with heart failure and how they map to HCCs.
ICD-10-CM HCC Mappings for Hypertension and Heart Failure
| DX | Description | V24 | V28 | RX – V08 |
|---|---|---|---|---|
| I10 | Essential (primary) hypertension | 187 | ||
| I11.0 | Hypertensive heart disease with heart failure | 85 | 226 | 186 |
| I11.9 | Hypertensive heart disease without heart failure | 187 | ||
| I50.1 | Left ventricle failure, unspecified | 85 | 226 | 186 |
| I50.20 | Unspecified systolic (congestive) heart failure | 85 | 226 | 186 |
| I50.21 | Acute systolic (congestive) heart failure | 85 | 225 | 186 |
| I50.22 | Chronic systolic (congestive) heart failure | 85 | 226 | 186 |
| I50.23 | Acute on chronic (congestive) heart failure | 85 | 224 | 186 |
| I50.30 | Unspecified diastolic heart failure | 85 | 226 | 186 |
| I50.31 | Acute diastolic (congestive) heart failure | 85 | 225 | 186 |
| I50.32 | Chronic diastolic (congestive) heart failure | 85 | 226 | 186 |
| I50.33 | Acute on chronic diastolic (congestive) heart failure | 85 | 224 | 186 |
| I50.40 | Unspecified combined systolic and diastolic (congestive) heart failure | 85 | 226 | 186 |
| I50.41 | Acute combined systolic and diastolic (congestive) heart failure | 85 | 225 | 186 |
| I50.42 | Chronic combined systolic and diastolic (congestive) heart failure | 85 | 226 | 186 |
| I50.43 | Acute on chronic combined systolic and diastolic (congestive) heart failure | 85 | 224 | 186 |
| I50.810 | Right heart failure, unspecified | 85 | 226 | 186 |
| I50.811 | Acute right heart failure | 85 | 225 | 186 |
| I50.812 | Chronic right heart failure | 85 | 226 | 186 |
| I50.813 | Acute on chronic heart failure | 85 | 225 | 186 |
| I50.814 | Right heart failure due to left heart failure | 85 | 226 | 186 |
| I50.82 | Biventricular heart failure | 85 | 226 | 186 |
| I50.83 | High output heart failure | 85 | 226 | 186 |
| I50.84 | End stage heart failure | 85 | 222 | 186 |
| I50.89 | Other heart failure | 85 | 226 | 186 |
| I50.9 | Heart failure unspecified | 85 | 226 | 186 |
Alright, let’s dive into a SOAP note example! We’ll look at how a patient with uncontrolled hypertension and chronic diastolic heart failure presents, then show how we abstract key information and assign the correct risk adjustment codes. It’s a great way to see coding in action linking conditions, following the hierarchy, and making sure every detail counts!
Patient Name: [Donna Doe]
DOB: [06/26/1975]
Date of Service: [08/20/2025]
S: Subjective (HPI)
Patient presents today with uncontrolled hypertension and complains of headaches and fatigue.
Review of Systems (ROS)
- Cardiovascular: Denies chest pain, palpitations
- Respiratory: Denies shortness of breath
- Neurologic: Headaches present
- General: Fatigue present
- Other systems: Negative
O: Objective
- BP: 150/92 mmHg
- HR: 80 bpm, regular
- RR: 18
- SpO₂: 97% on room air
- Mild bilateral ankle edema
- Heart: S1/S2, no murmurs
- Lungs: Clear
A: Assessment
- Primary: Hypertension, uncontrolled
P: Plan
- Continue Metoprolol 50 mg PO BID
- Continue Coreg (Carvedilol) 12.5 mg PO BID
- Acetaminophen (Tylenol) PRN for headaches
- Monitor BP at home; maintain log
- Low-sodium diet, regular exercise
- Follow-up in 1 month or sooner if symptoms worsen
Problem List:
- Hypertension
- Chronic diastolic heart failure
- Migraines
- GERD
- Edema
Medication List:
- Metoprolol 50 mg PO BID
- Coreg (Carvedilol) 12.5 mg PO BID
- Acetaminophen (Tylenol) PRN
Following risk adjustment best practices, we’ve identified the key elements needed to code this chart. Hypertension is documented in both the assessment, HPI, and problem list in following the hierarchy we abstract from the assessment as the highest chart component. Chronic diastolic heart failure appears in the problem list, and the patient’s medications support both conditions. With all these elements in place, we are now ready to link hypertension to heart failure for accurate coding!
Let’s Index
Hypertension is coded as (I10) and is documented as Essential Primary Hypertension. When linking Hypertension to Heart failure we index by Hypertension > with > Heart Failure and we arrive at code (I11.0) and are instructed to “code also” the type of heart failure from category block (I50. -).
✅ Final Code Assignment:
- I11.0 – Hypertensive heart disease with heart failure
- I50.32 – Chronic diastolic (congestive) heart failure
Works Cited
- Centers for Medicare & Medicaid Services. ICD-10-CM 2025 Official Coding Guidelines. CMS, 2025, https://www.cms.gov/medicare/icd-10/2025-coding-guidelines.
- Pope, Sheri Bernard. Risk Adjustment: Clinical Documentation and Coding. 2nd ed., [Publisher], 2022.
- Centers for Medicare & Medicaid Services. ICD Initial Mappings 2026. CMS, 2026, https://www.cms.gov/medicare/icd-initial-mappings-2026.
- RxList.com. Drug Information and Resources. https://www.rxlist.com.