Top 5 HCC Coding Mistakes and How to Avoid Them
Even the most experienced medical coders and providers can fall into common traps when it comes to Hierarchical Condition Category (HCC) coding. Mistakes can lead to claim denials, inaccurate RAF scores, compliance risks, and lost revenue. Below are five of the most common HCC coding mistakes with detailed explanations and practical strategies for prevention.
Table of Contents
1. Incomplete or Missing Documentation
This is the most frequent mistake in HCC coding. If a diagnosis isn’t properly documented in the patient’s medical record, it cannot be coded. For instance, simply writing "diabetes" without context is insufficient. Auditors expect to see supporting details that demonstrate the condition is current and actively managed.
How to avoid it:
Use the MEAT criteria for every chronic condition:
Monitored (labs, vitals, imaging)
Evaluated (test results, response to treatment)
Assessed/Addressed (clinical status, progression)
Treated (medications, lifestyle counseling, referrals)
Educate providers on what constitutes adequate documentation.
Conduct regular internal audits to catch gaps before claims are submitted.
2. Undercoding or Not Capturing All Conditions
Under coding occurs when providers fail to document or coders fail to capture all active chronic conditions. For example, coding only diabetes in a patient who also has hypertension and a history of heart attack results in a lower RAF score than appropriate.
How to avoid it:
Perform problem list reviews at every visit.
Use EHR alerts to prompt providers about unresolved or unaddressed chronic conditions.
Schedule annual wellness visits specifically designed to address and document all chronic conditions.
Engage coders in retrospective chart reviews to identify missed opportunities.
3. Failing to Be Specific (Using Unspecified Codes)
Using unspecified codes when a more detailed diagnosis exists reduces accuracy. For example, coding “Type 2 diabetes mellitus” instead of “Type 2 diabetes with chronic kidney disease” can cause a missed HCC and underestimate patient risk.
How to avoid it:
Encourage coding to the highest level of specificity.
Provide ICD-10-CM coding education tailored to common chronic conditions.
Leverage EHR tools that display more precise code suggestions.
Establish query processes so coders can request clarification from providers when documentation is vague.
Read how How Accurate HCC Coding Improves Patient Care here.
4. Not Capturing a Diagnosis Annually
HCC codes reset every calendar year. If a chronic condition is not recaptured annually, it is excluded from the RAF calculation. For example, if a patient’s COPD isn’t coded in 2025—even though it was managed in 2024—it won’t contribute to the 2025 RAF score.
How to avoid it:
Develop a recapture protocol:
Run monthly or quarterly reports to flag patients with chronic conditions not documented in the current year.
Reach out proactively to schedule follow-up visits.
Use EHR checklists and templates that remind providers to readdress chronic conditions.
Incorporate RAF recapture into quality and compliance dashboards.
5. Misunderstanding the HCC Hierarchy
The HCC system is hierarchical, meaning only the most severe condition in a category is used for scoring. For example, a patient with chronic kidney disease (CKD) and end-stage renal disease (ESRD) only receives credit for ESRD. Attempting to code both is incorrect and can trigger an audit.
How to avoid it:
Provide formal HCC hierarchy training to coders and clinical staff.
Use HCC coding software that automatically applies hierarchy rules.
Perform manual quality checks to confirm that the logic applied by software matches clinical intent.
Educate providers about why one diagnosis may be prioritized over another in risk adjustment.\
Quick Reference Checklist for Coders and Providers
- Apply MEAT criteria to every documented chronic condition.
- Review problem lists and ensure all active conditions are coded.
- Code to the highest level of specificity (avoid unspecified codes).
- Confirm annual recapture of all chronic conditions.
- Understand and apply the HCC hierarchy properly.
- Use EHR tools and alerts to support coding accuracy.
- Perform regular audits to catch and correct errors early.
- Educate and retrain staff on ICD-10-CM updates and HCC guidelines.
- Establish a query process for unclear documentation.
- Incorporate HCC coding performance into quality dashboards.
Final Thoughts
Avoiding these top five mistakes significantly improves RAF accuracy, compliance, audit readiness, and reimbursement integrity. By focusing on thorough documentation, capturing all conditions, coding with specificity, annual recapture, and understanding hierarchy rules, practices can safeguard revenue while ensuring accurate reflection of patient complexity.
Also, Find out HCC Medical Abbreviation: Uses in Coding and Cancer Context in medical billing.
