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Provider Manual

Risk Adjustment - Diabetes

Last Updated on January 24, 2019

Hierarchical Condition Category Coding and Diabetes

The Center for Medicare and Medicaid Services (CMS) has associated diabetes and several of its manifestations with Hierarchical Condition Category (HCC) codes.  Security Health Plan has found that provider’s often document and code for a patient’s diabetes, but do not document and code for the complications diabetes causes.  If complications are present, the causal relationship between the conditions should be clearly documented and the conditions diagnosed and coded to the highest degree of specificity possible.  The International Classification of Diseases-10 (ICD-10) identifies approximately 200 ICD-10 codes that indicate diabetes mellitus type I, type II or secondary diabetes mellitus and its manifestations.  These 200 codes map to one of the following 3 HCC.

  • HCC17 – Diabetes with Acute Complications
  • HCC18 – Diabetes with Chronic Complications
  • HCC19 – Diabetes without Complication

Accurate ICD-10 coding along with complete and accurate patient documentation is required to support submission of any HCC to CMS.

Coding Diabetes

Diabetes is associated with a risk of complications that may affect one or more of an individual’s organ systems.  Documentation and the ICD 10 code submitted by a provider for patient services should reflect the relationship between the condition and severity of disease. The following list related to diabetes provides details used to determine correct coding.  Is the diabetes:

  • Type I or Type II
  • Secondary to another condition
  • With or without complications
  • With ketoacidosis
  • With hyperosmolarity
  • With coma
  • With renal manifestations
  • With ophthalmic manifestations
  • With neurological manifestations
  • With peripheral circulatory disorders
  • With other specified manifestations (ulcer & location, chronic ulcer)
  • With unspecified complication

Important coding note:  When a patient has diabetes and a manifestation of it,   both   conditions should be coded for the patient (i.e. neuropathy due to diabetes, chronic kidney disease secondary to diabetes).

Documentation to Support Diabetes Coding

Documentation should clearly state the member has diabetes and describe any complications associated with it.  Clearly establishing the causal relationship between the conditions is important when it is the provider’s impression that diabetes has caused one or more complications.  Words that are helpful to create this relationship include “due to”, “because of”, “secondary to” or “related to”.  Providers may also use the word “diabetic” to show that diabetes is the root cause of the manifestation. 

Documentation should include the following about the patient:  

  • Current diagnosis of diabetes (Secondary, Type I or Type II)
    • Stating   “history of diabetes”    or listing diabetes in the “Past Medical History”   does   not   indicate that it is a current, active problem for the patient
    • Status of diabetes (stable, with or without complication, blood sugars, A1c, concerns, pertinent exam, etc)
    • The symptoms associated with any manifestations/complication of diabetes
    • Assessment
    • Management/Treatment plan
      • Labs ordered
      • Referrals made and reason for the referral (diabetic education, endocrinology)
      • Medication – adjustment or continue medication (coders cannot infer what a medication is for when only listed on a medication list)
      • Continue current regimen
      • How diabetes or its treatment impact treatment of other conditions the patient may have

HCC considerations

Documentation and coding related to any chronic condition, including diabetes, must be completed at least once each calendar year.  Additionally, every medical record document must contain the following:

  • Date of service
  • Patient name & date of birth
  • Provider signature & credentials
  • Legible handwriting (when applicable)
  • Industry standard abbreviations
  • An evaluation statement

Questions

Brenda Anderson
Revenue Management Educator
Security Health Plan 
Telephone: 715-221-9598

Ann Meverden
Revenue Management Educator
Security Health Plan 
Telephone: 715-221-9352

Shared email:   rf.shp.risk.adjustmnt@securityhealth.org