Hepatocellular carcinoma (HCC) is the third most common cause of cancer-related death worldwide and one of the most common causes of death in patients with cirrhosis. Although it has a lower incidence in the United States than other countries, its incidence is dramatically on the rise. HCC surveillance is recommended at regular intervals in patients with cirrhosis to detect tumors at an early stage, when curative options exist. Ultrasound and alpha-fetoprotein remain the surveillance tests of choice and should be used in combination every 6 months until better surveillance tools become available. Unfortunately, HCC surveillance continues to be underutilized in clinical practice, with less than 20% of at-risk patients undergoing surveillance. This is related to multiple causes, including underrecognition of liver disease and cirrhosis in approximately 40% of patients; however, the most common reason is a failure to order surveillance in those with known cirrhosis.