Certified Risk Adjustment Coder (CRC)

Which provider is NOT approved for diagnosis code capture under the Medicare HCC model?

1. Gynecologist

2. Pathologist

3. Oral surgeon

4. Registered Nurse

The correct answer is: Registered Nurse

In the context of Medicare’s Hierarchical Condition Category (HCC) model, only certain providers are qualified to capture diagnosis codes that can impact risk adjustment. Providers such as gynecologists, pathologists, and oral surgeons are typically involved in direct patient care and can document conditions that affect a patient's health status. Registered nurses, while critical to patient care and often involved in patient assessment and management, are not considered qualified providers for the purpose of capturing diagnosis codes under Medicare's HCC model. This stems from the guidelines set forth by the Centers for Medicare & Medicaid Services (CMS), which designate specific licensed professionals—like physicians—who can establish and validate diagnoses for risk adjustment. Therefore, a registered nurse does not fulfill the criteria necessary to contribute to diagnosis code capture in the way that physicians and certain specialists do. This distinction is crucial as it impacts how care is documented and how risk adjustment factors into payment models under Medicare. Understanding these roles helps clarify the Medicare framework and the importance of proper documentation in coding practices.