HCC Guidelines

The Importance of Adhering to HCC Guidelines

The Hierarchical Condition Categories (HCC) was developed and implemented by The Centers for Medicate and Medicaid (CMS) in order to create a risk adjustment methodology to provide adequate payment plans for patients opting for private health care. These codes are primarily based on the health expenditure risk profiles of the Medicare Advantage (MA) plan members; and the CM Risk Adjustment Model also measures the disease that correlate the ICD diagnosis codes. Adhering to HCC coding guidelines helps group the diseases and ergo the procedures in a system based on their medical and financial conditions.

Risk adjustment in HCC

Risk adjustment in the CMS- HCC model characteristics is based on multiple factors, which are analyzed and reduced to offer the right risk management plan for a patient. The factors that influence risk adjustment includes:

  • Hierarchy of diseases: Ensuring that diagnoses are included in the appropriate disease groups and are in accordance with the necessary hierarchy.
  • Disease Interactions: The additional factors that recognize and assess the severity of multiple conditions.
  • Demographic Variables: These focus on the demographic of the patient’s living conditions and demographics.
  • Diagnostic Sources: CMS recognizes diagnoses from a hospital’s inpatient, outpatient and physician settings only.
  • Prospective model: The diagnoses based on last year are used to extrapolate the possible payments for the next year.

Multiple conditions

A patient can have multiple HCC categories assigned to them based on their medical conditions. In some cases, specific conditions can override others, when documenting. This is based on the strict hierarchy of the coding procedures.

HCCs are captured once a year, every year in order for the CMS to reimburse payments to the Medicare Advantage. However, diagnoses from previous years are used to establish capitation payments to the Medicare Advantage plan.

Gathering accurate data

One of the key features of dealing with HCCs is collecting proper data from the patients in order to use the right codes. This is the physician’s responsibility to gather and furbish accurate patient information and diagnosis. Inability to do so, will limit the resources that a physician is viable to use form the accredited healthy plan, thus limiting growth in their sector.

Good documentation should begin form the time the doctor meets the patient and should record all their medical problems, history, symptoms and other medical record that helps ascertain the ICD-100CM codes.

Coding methodology

The coding strategy of HCC is quite simple. It is designed to score reimbursements from CMS and Managed Medicare Plans. Here, all the diagnosis made on the patient should be done by a credible physician either NP or PA.

HCC takes into consideration multiple documentations such as patient care, treatment, management etc. However, conditions that were previously treated whose codes no longer exist need not be documented for this purpose.

HCC CMS coding guidelines also allow for incorporating a combination of codes, depending on the persisting condition of the patient. A combination of codes can occur if the patient has two diagnoses, a diagnosis with an additional process or a diagnosis that has secondary associated complication.

Why MedConverge

MedConverge is one of the most reliable HCC medical coding companies, and out experts are proficient in the regulations set up by governing bodies that oversee Georgia medical billing services. For more information about our full range of services, do write to us at or call us on (800) 898-0709.


  1. Definition of HCC. (2017). Retrieved January 13, 2017, from
  2. HCCs: Easy as 1, 2, 3 (the culture of MEAT). (2014, March 19). Retrieved January 12, 2017, from
  3. Lynn Myers MD, C. C. (2017). HCC CODING – A Documentation Strategy. Retrieved January 12, 2017, from
  4. Tonya Ries, B. C. (2016, February 18). Introduction to Risk Adjustment, Documentation & Coding Best Practices. Retrieved January 12, 2017, from

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