HCC (Hierarchical Condition Category)
Hierarchical Condition Category
The CMS risk-adjustment model that groups ICD-10 codes into categories used to predict the cost of care for Medicare Advantage enrollees.
1 min read · Last reviewed May 23, 2026
At a glance
- Category
- Documentation
- Acronym for
- Hierarchical Condition Category
- Primary sources
- 1
- Workspace handoff
- revenue audit →
Where this comes up
Providers meet this term in the chart and at the post-visit review — encounter notes, problem lists, medication reconciliation, signed orders, and the time/elements that defend the billed code. If documentation does not support the code, the code does not survive an audit.
Full definition
What it is in practice
CMS maintains the CMS-HCC model. Each HCC carries a risk factor that, combined with demographics, generates the patient's risk score. The score drives the Medicare Advantage capitation rate.
How it shows up in your practice
In value-based and MA contracts, accurate HCC capture meaningfully affects revenue. Audit charts annually to ensure relevant chronic conditions are coded each year.
Sources
- CMS — Medicare Advantage (Part C)https://www.cms.gov/medicare/health-plans/medicareadvtgspecratestats
Audit HCC recapture in Revenue Audit
Open revenue audit →Related terms
- DocumentationProblem ListThe structured list of active and resolved diagnoses maintained in the electronic health record.
- Compliance ProgramValue-Based CareReimbursement models that pay providers based on quality and outcomes rather than fee-for-service volume.
- CodingICD-10-CMThe Clinical Modification of the WHO ICD-10 code set used in the United States to report diagnoses.
- DocumentationDocumentation SpecificityThe level of detail in clinical documentation needed to support the diagnosis and service codes reported.
- PayerMedicare Part C (Medicare Advantage)Medicare benefits delivered through private health plans contracted with CMS, often with additional benefits and a managed-care structure.
D3rx is a healthcare-billing and compliance research aid maintained by D3rx Inc. Articles are drafted by an LLM (Anthropic Claude) against primary HHS, OCR, CMS, eCFR, NIST, and state-regulator publications, and reviewed for restraint and source fidelity by the D3rx team.
Reviewer status: a named credentialed reviewer (CHC, CHPC, or healthcare attorney) is being engaged. Until that engagement is finalized, this page does not claim credentialed review.
Related across the archive
- GlossaryMedicare Part C (Medicare Advantage)Medicare benefits delivered through private health plans contracted with CMS, often with additional benefits and a managed-care structure.
- GlossaryDocumentation SpecificityThe level of detail in clinical documentation needed to support the diagnosis and service codes reported.
- GlossaryProblem ListThe structured list of active and resolved diagnoses maintained in the electronic health record.
- GlossaryICD-10-CMThe Clinical Modification of the WHO ICD-10 code set used in the United States to report diagnoses.
- GlossaryValue-Based CareReimbursement models that pay providers based on quality and outcomes rather than fee-for-service volume.
- GlossaryACA Marketplace PlanHealth plans sold through the federal or state-based health insurance marketplaces under the Affordable Care Act.
- GlossaryMedicare Stars RatingFive-star quality rating system CMS publishes annually for Medicare Advantage and Part D plans.
- GlossaryMental Health ParityFederal and state laws requiring health plans to apply benefits and access requirements to mental health and substance use treatment that are no more restrictive than those for medical/surgical care.
This glossary entry is a research aid for billing and compliance staff. It does not provide legal, medical, or financial advice and does not replace counsel. References cited link to primary sources at HHS, OCR, CMS, eCFR, NIST, and the relevant payer or industry body.