HCC Coding

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HCC Coding Hierarchical Condition Categories, referred to as HCC, is a method of maximizing services to patients while receiving additional revenue to cover such services. HCC incorporates clinical documentation, coding, auditing and reimbursement. Leaving a diagnosis under documented, not substantiated or not coded could result in loss of thousands of dollars per patient. When implemented correctly, the benefits impact the patient, the organization and the healthcare community.

Payers reimburse hospitals and providers a flat-fee per patient, known as capitation. With HCC, in addition to the flat fee, for management of designated chronic diseases, payers increase reimbursement for the care and treatment of such diseases. This is referred to as “volume-to-value” and by 2020 will be the way in which 80% of contracts across all payers are designed. It is still referred to as a “risk-based agreement” because the provide shoulders rendering services, properly documenting and coding to achieve an increased fee to cover the additional services patients require to improve conditions such as laboratory, screenings and additional office visits, all ultimately resulting in less medications and hospitalizations.

  • HCC reimbursement rates are increasing over the next three years
  • There is a financial benefit to providers and payers for correctly capturing all HCC codes
  • There are approximately 11,000 codes that map to HCCs that need to be understood and captured

HCC Coding:

  • Reviews HCC medical records and coding both concurrently & retrospectively 
  • Evaluation of HCC Program with Findings and Recommendations
  • Training of Providers, typically web-based
  • Post provider training, re-audit/evaluate sample of HCC records



MMGS provides the following additional steps to ensure the most complete HCC Coding and the greatest opportunity for reimbursement for clients:

  • Discovery
    • Information Gathering to maximize Findings e.g. Preliminary RFA17 EAPG Weights
    • Perform a scoping e.g. Community Health Center, Accountable Care Organization, Hospital ACO, etc.
      • Count(s)
      • Weight(s)
      • Reimbursement
      • ICD-10 CM diagnosis codes with EAPG Assignment
      • HCPCS codes with EAPG Assignment
      • New and deleted HCPC codes
      • SME recommendations on sample size to establish a baseline for organization.
  • Evaluate and validate existing population
  • Review potential shifts in chronic conditions
  • Validate coding compliance, both technical and process
  • Summary of Findings
    • Scorecard (Baseline & Range, Averages, Target Areas, etc.)
    • Opportunities
      • Program
      • Documentation
      • Coding
      • Auditing
      • Technology Review
    • Population Health
      • Over/under utilization of patient care services
      • Over/under staffing of clinical staff to serve patient base 
      • Ancillary services to maximize patient care
      • Medication Management
      • Shortfalls of coordination of care for overlapping chronic conditions 
      • Over/under utilization of laboratory services
      • Over/under utilization of screenings e.g. colon, cardiac, etc.

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