Diabetes coding in Hierarchical Condition Coding (HCC)

• Diabetes is a common chronic condition, included in three distinct HCC categories
• Patients often have more than one chronic condition of the disease; page down for a Q&A related to how multiple conditions do–and don’t–affect the risk score

CodingIntel members can download our guide to Risk adjusted diagnosis coding for medical practices for more explanation and examples.  This article is specific to diabetes.

9.4% of Americans have diabetes, and in some states, the incidence of diabetes reaches almost 15%. Medical practices in ACOs or with commercial risk contracts can provide the payer with an accurate picture of their patients’ disease burden and health status through diagnosis coding on claims forms.  Since diabetes is so prevalent, this is a good place to start.

HCC coding for Diabetes

HCC 17           Diabetes with acute complications                  RAF 0.302[1]
HCC 18           Diabetes with chronic complications              RAF 0.302
HCC 19           Diabetes without complications                      RAF 0.105

• ICD-10 codes for diabetes with complications carry a RAF three times higher than E11.9, diabetes uncomplicated
• Although the words “controlled” and “uncontrolled” appear in many EMR definitions of diabetes, the ICD-10 definitions are not defined with those words
• Although conditions in the same category count only once, most groups want to capture all of the diabetic complications in the patient’s problem list
• If a patient had a diabetic complication, use it instead of code E11.9
• For E11.69, diabetes with other specified complication, add a code for that additional complication
• For some conditions (see below) add a code for the specific type of disease (CAD, for example) or for the state or severity

[1] All of the values in this guide use the coefficient for a person living in the community, non-dual eligible for Medicare and Medicaid, aged.

Question: Can we code diabetes with complications and long-term use of insulin together? This is important because long-term use of insulin has a risk adjustment factor for HCCs, and we don’t want to miss it.

Answer: Diabetes codes are included in three HCC categories:

HCC 17: Diabetes with Acute Complications                        RAF score 0.302
HCC 18: Diabetes with Chronic Complications                    RAF score 0.302
HCC 19: Diabetes without Complications                             RAF score 0.105

Long-term use of insulin is in HCC 19.  Reporting this code with another diabetes code does not increase your risk score, because of the HCC hierarchy trumping rules.

Here are the hierarchy rules that affect this:

• Two conditions in the same category are counted only once. Example: E11.9 and Z79.4 are both in HCC category 19, with a RAF score of 0.105. When both are reported, the RAF score is 0.105, not doubled.
• When a more severe condition is reported with a less severe related condition, the most severe condition trumps the less severe. Reporting a diabetes code with a chronic complication is in HCC 18, RAF score of 0.302. If you report diabetes with a chronic complication and Z79.4, long term current use of insulin, (HCC 19, RAF 0.105) only the higher score is calculated. The two scores are not added together.
• Let’s say a patient develops hyperglycemia mid-year. E11.9 is reported by her physician in January. This is HCC 19. In July, code E11.65 is reported. E11.65, type 2 diabetes with hyperglycemia is in HCC 18, which carries a higher weight. For that year, the patient’s risk score is based on the higher value. The two values are not additive, because they are related conditions, and the more serious one is counted.
• And remember, “reported” means in the calendar year, not necessarily on the same claim.

This doesn’t mean you should report Z79.4, only that it does not increase your risk score.

Additional resources

The Diagnosis coding section of CodingIntel includes additional resources for HCC and ICD-10 coding.

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