Diabetic HCCs: Documenting and capturing complications

According to the Center for Disease Control’s National Diabetic Statistics Report 2020, there are 34 million people in the United States that have diabetes. That is 11 percent of the population. In people over the age of 65, 27 percent have diabetes. Diabetes is the leading cause of new cases of blindness among adults ages 18-64 years old. Complete and accurate documentation of diabetes and its complications is critical to reflect the clinical complexity of diabetic patients.

Diabetic diagnosis hierarchical condition categories (HCCs)

There are three HCCs for diabetic diagnoses:

HCC 17 Diabetes with Acute Complications

HCC 18 Diabetes with Chronic Complications

HCC 19 Diabetes without Complication

HCC 17, HCC 18, and HCC 19 have diabetic diagnoses that begin with ICD-10-CM categories:

E08 – Diabetes mellitus due to underlying condition​

E09 – Drug or chemical induced diabetes mellitus​

E10 – Type 1 diabetes mellitus​

E11 – Type 2 diabetes mellitus​

E13 – Other specified diabetes mellitus

The categories are further divided into subcategories with acute complications, chronic complications or without complications.

The three diabetic HCCs are part of a hierarchy, where HCC 17 is ranked highest and HCC 19 is ranked lowest. For risk score calculation, only diagnoses within the highest ranked HCC within a hierarchy are captured for a patient encounter. Not all HCCs are part of a hierarchy, which makes documenting diabetic diagnoses to the greatest specificity so important.

The category HCC 17, Diabetes with Acute Complications, has 23 diagnoses that would warrant an inpatient hospitalization and may be seen in a patient presenting to an emergency department. Diagnoses included in HCC 17 are diabetic ketoacidosis, hypoglycemia or hyperosmolarity, with or without coma. Patients with acute, life threatening complications such as these often use the greatest amount of health care resources, and this is noted in the CMS HCC V24.0 risk adjustment factor of 0.302 for HCC 17.  

Category HCC 19 Diabetes without Complication has only 6 diagnoses. Diagnoses included are diabetes without complications and the diagnosis long term use of insulin. Five of the six diagnoses have “without complications” in their narrative description and the lowest CMS HCC V24.0 risk adjustment factor of 0.105 within the hierarchy. HCC 19 has the greatest opportunity for clinical documentation specialists in reviewing documentation, looking for clinical indicators, lab values and abnormalities in the physical exam to generate a compliant query for diabetes specificity.

The category HCC 18, Diabetes with Chronic Complications, has 400 diagnoses and includes chronic diabetic complications of neuropathy, retinopathy and chronic kidney disease to list a few. HCC 18 has a CMS HCC V24.0 risk adjustment factor of 0.302. Patients with diabetes are susceptible to chronic conditions that affect renal, nervous and cardiovascular systems. Many patients have several diabetic complications concurrently. Documenting and coding the progression of diabetes and the associated complications is so important in today’s quality and risk adjustment world.

With the adoption of ICD-10-CM, the concept of combination codes was expanded. ICD-10-CM combination codes include the diabetic complication as well as the diabetes itself. ICD-10-CM Official Guidelines for Coding and Reporting, Section 1, A, 15 of the guidelines states:

“The word ‘with’ or ‘in’ should be interpreted to mean ’associated with‘ or ’due to‘ when it appears in a code title, the Alphabetical Index, or an instructional note in the Tabular List. The classification presumes a causal relationship between the two conditions linked by these terms. These conditions should be coded as related even in the absence of provider documentation explicitly linking them, unless the documentation clearly states the conditions are unrelated or when another guideline exists that specifically requires a documented linkage between the two conditions.”

This guideline applies to all complications listed under the word “with” in the diabetes listing found in the Alphabetical Index. So, unless the physician clearly documents that a complication is not due to diabetes or there is a diabetic complication documented that is listed as “not elsewhere classified” (NEC) in the Alphabetical Index, for example, diabetes with skin ulcer NEC, the NEC complications require a direct linking by the physician to the diabetes.

Other examples of NEC complications under the diabetes listing are circulatory complication NEC, kidney complication NEC, neurologic complication NEC, ophthalmic complication NEC, oral complication NEC and renal complication NEC. These complications would require a linking to the diabetes documented by the physician.

HCC 17, HCC 18 and HCC 19 require complete and accurate documentation and coding to capture the diagnosis and disease progression of diabetes. With almost 30 percent of the population over the age of 65 diagnosed with diabetes, it is more important than ever to document the complications and treatment of these patients.

Chris Berg, RHIA, CCS, CCDS-O, CHC is an Ambulatory Services Consultant for 3M Health Information Systems.