Hierarchical Condition Category (HCC)

HCC (Hierarchical Condition Category) Coding is a method used in medical billing and reimbursement to categorize and group conditions and diseases of patients based on their impact on expected healthcare utilization and cost.

The categories are hierarchical, meaning they are organized in a structure that places similar conditions and diseases into a group. The HCC system is used by Medicare Advantage (MA) plans to determine the risk adjustment factor for payments.

HCC relies on ICD-10 coding for risk to be assigned to patients in the form of a Risk Adjustment Factor or RAF score. Each HCC is mapped to one or more ICD-10 codes. So, a patient with multiple chronic conditions will have a RAF score assigned based on these conditions and the corresponding HCC and ICD-10 codes. 

Vim’s Diagnosis Gaps solution is used by the top health plans to help increase risk adjustment accuracy at the point of care. Payer-sourced suspected diagnoses are embedded directly into provider EHRs, surfacing patient-specific condition gaps and assisting providers in quickly and easily taking appropriate actions for accurate and efficient risk adjustment processes.