Hierarchical Condition Categories (HCC)

Hierarchical Condition Categories (HCC): An Exhaustive Guide with ICD-10 and Industry Use-Cases

Hierarchical Condition Categories (HCCs) are a cornerstone in modern risk-adjusted reimbursement models used by Medicare Advantage (MA), Accountable Care Organizations (ACOs), Medicaid, and commercial health plans. Each HCC represents a grouping of related ICD-10 codes that describe severe, chronic, or costly medical conditions. The Centers for Medicare & Medicaid Services (CMS) assigns weights to these HCCs for risk adjustment and payment calculations.

Understanding the HCC hierarchy and aligning ICD-10 coding with these categories is vital for healthcare providers, payers, and technology partners. With value-based care growing in prominence, mastering HCC usage isn't just about reimbursement—it's about delivering better care, efficiently.

This article provides an exhaustive list of major HCC categories, examples of relevant ICD-10 codes, and typical industry scenarios where they play a critical role.

1. HCC 85 – Hypertensive Heart Disease or Chronic Kidney Disease

  • Example ICD-10 Code: I10 – Essential (primary) hypertension

  • Use Case: Used in risk scoring for patients with long-term cardiovascular complications, especially in MA plans.

2. HCC 22 – Morbid Obesity

  • Example ICD-10 Code: E66.01 – Morbid (severe) obesity due to excess calories

  • Use Case: Important in predicting resource utilization in bariatric surgery candidates or chronic disease management.

3. HCC 18 – Diabetes with Chronic Complications

  • Example ICD-10 Code: E11.22 – Type 2 diabetes mellitus with diabetic chronic kidney disease

  • Use Case: Flagged in diabetic patient registries and used in care coordination, especially for CKD or retinopathy.

4. HCC 19 – Diabetes without Complication

  • Example ICD-10 Code: E11.9 – Type 2 diabetes mellitus without complications

  • Use Case: Typically used in baseline risk assessment for MA or CMS-HCC risk models.

5. HCC 108 – Vascular Disease

  • Example ICD-10 Code: I73.9 – Peripheral vascular disease, unspecified

  • Use Case: Common in patients undergoing angioplasty or stent placement; used in ACO performance scoring.

6. HCC 96 – Specified Heart Arrhythmias

  • Example ICD-10 Code: I48.91 – Unspecified atrial fibrillation

  • Use Case: Critical for risk prediction in cardiology practices, anticoagulation management programs.

7. HCC 85 – Congestive Heart Failure (also grouped under hypertensive complications)

  • Example ICD-10 Code: I50.9 – Heart failure, unspecified

  • Use Case: High weight in CMS models due to readmission risks and care intensity.

8. HCC 111 – Chronic Obstructive Pulmonary Disease (COPD)

  • Example ICD-10 Code: J44.9 – COPD, unspecified

  • Use Case: Used in pulmonology workflows and for remote patient monitoring reimbursement.

9. HCC 96 – Atrial Fibrillation and Flutter

  • Example ICD-10 Code: I48.91 – Atrial fibrillation

  • Use Case: Used to adjust risk in stroke prevention and anticoagulation therapy registries.

10. HCC 148 – Rheumatoid Arthritis and Inflammatory Connective Tissue Disease

  • Example ICD-10 Code: M06.9 – Rheumatoid arthritis, unspecified

  • Use Case: Specialty plans and biologic drug reimbursement tracking.

11. HCC 59 – Major Depressive, Bipolar, and Paranoid Disorders

  • Example ICD-10 Code: F33.1 – Major depressive disorder, recurrent, moderate

  • Use Case: Behavioral health integration and mental health reimbursement prioritization.

12. HCC 157 – Amputation Status, Lower Limb/Amputation Complications

  • Example ICD-10 Code: Z89.511 – Acquired absence of right leg below knee

  • Use Case: Used in prosthetics reimbursement, wound care programs, and mobility aid evaluation.

13. HCC 160 – Major Joint Replacement or Spinal Surgery

  • Example ICD-10 Code: M17.12 – Unilateral primary osteoarthritis, left knee

  • Use Case: Relevant in orthopedic surgery risk adjustment and preauthorization systems.

14. HCC 134 – Dialysis Status

  • Example ICD-10 Code: Z99.2 – Dependence on renal dialysis

  • Use Case: Applies to ESRD risk models and dialysis center capitation models.

15. HCC 136 – Chronic Kidney Disease, Stage 5

  • Example ICD-10 Code: N18.5 – CKD stage 5

  • Use Case: Captured in nephrology clinics, used for high-risk flagging in ACOs.

16. HCC 9 – Lung and Other Severe Cancers

  • Example ICD-10 Code: C34.90 – Malignant neoplasm of unspecified part of unspecified bronchus or lung

  • Use Case: Used to calculate cost risk in cancer-focused centers and oncology drug trials.

17. HCC 8 – Metastatic Cancer and Acute Leukemia

  • Example ICD-10 Code: C77.0 – Secondary and unspecified malignant neoplasm of lymph nodes of head, face, and neck

  • Use Case: Triggers high-value reimbursements and case management in advanced disease.

18. HCC 56 – Substance Use Disorders

  • Example ICD-10 Code: F11.20 – Opioid dependence, uncomplicated

  • Use Case: Behavioral health reimbursements, integrated MAT (medication-assisted therapy) models.

Industry Applications of HCC Models

HCC models are widely used across the healthcare industry:

  • Medicare Advantage Plans: Adjust premiums and reimbursements based on patient risk.

  • ACO and Value-Based Care Models: Predict resource utilization and care needs.

  • Population Health and Care Management: Identify high-risk patients for proactive intervention.

  • Revenue Cycle and CDI Teams: Ensure accurate coding for maximum appropriate reimbursement.

  • Risk Adjustment Vendors and Coding Auditors: Analyze documentation gaps and validate HCC capture.



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