HCC Coding Tips: Diabetes and Complications

Accurately coding patient complexity has a heavy influence on how CMS sets our network’s financial benchmark. Here are a few tips from our HCC coding resource about capturing the complexity of your diabetic patients.

What type is it? Five Main Categories:

  • Diabetes mellitus due to underlying condition = E08._
  • Drug or induced diabetes mellitus = E09._
  • Type I diabetes mellitus = E10._
  • Type II diabetes mellitus = E11._
  • Secondary diabetes mellitus NEC = E13._

Capturing Complexity

Most complications are built into the code for diabetes.
Example: Inadequately controlled, poorly controlled, or out of control type II diabetes with hyperglycemia =E11.65 (add Z79.4 for insulin use)

There are a few that require a second code to identify the specific manifestation:

  • Chronic kidney disease requires an additional code to identify the stage of disease = N18.1 – N18.6 (ex. CKD stage 3 = N18.3)
  • Foot ulcers require another code to identify the site = L97.4 – L97.5 (ex. ulcer of left heel and midfoot with fat layer exposed = L97.422)
  • Other skin ulcers = L97.1 – L97.9, L98.41 – L98.49 (ex. ulcer of right calf with necrosis of muscle = L97.213)
  • Any insulin use = Z97.4

Documentation to Support Coding

All diabetic complications must be documented as a cause-effect relationship. Diagnoses must be connected in the assessment in order to code a complication related to diabetes. For example, “Type II diabetes with polyneuropathy” can be coded as E11.42. However, “Type II Diabetes” and “Polyneuropathy” documented as two distinct diagnoses must be coded seperately and would communicate a less serious diabetes case.