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In the CMS-HCC model, many related conditions are organized intohierarchiesso that only themost severemanifestation within a disease family contributes to the RAF. This prevents double counting when multiple codes describe progressive severity of the same underlying condition. Cancer categories are a common example: a diagnosis reflectingmetastatic diseaserepresents substantially higher expected resource utilization than a diagnosis of localized/primary malignancy. In this scenario, the February prostate cancer maps to a lower-severity HCC (HCC 23), while the October documentation of prostate cancerwith bone metastasesmaps to a higher-severity HCC (HCC 18). When both are captured within the applicable period, the hierarchy logic retains thehigher-weighted metastatic categoryand suppresses the lower category. The timing of which was coded first does not control the hierarchy outcome, and both HCCs are not counted together when they fall within the same hierarchical grouping. Therefore, the patient’s risk score calculation reflects HCC 18 rather than HCC 23.

In the outpatient/ambulatory setting, ICD-10-CM reporting rules applied in CDI education distinguish clearly between confirmed diagnoses and “uncertain” or “rule out” conditions. Terms such as “rule out,” “suspected,” or “probable” generally are not coded as established diagnoses in the outpatient record because the encounter is often for evaluation and testing rather than definitive confirmation. Instead, coders report the patient’s presenting signs and symptoms when a definitive condition has not been documented as confirmed by the provider. Here, the clinician ordered diagnostic testing (ECG and chest x-ray) specifically to rule out myocardial infarction (MI), but no final diagnosis of MI or angina is documented in the scenario. Therefore, “rule out MI” is not reportable, and neither is acute MI or angina unless explicitly diagnosed. The reportable conditions are the symptoms that drove the visit and required evaluation: chest pain (captured as “other chest pain” in the options), shortness of breath, and nausea.