Condition guide
Diabetes Mellitus (Type 2) HCC Coding Guide
Diabetes Mellitus (Type 2) (e.g. E11.22) maps to HCC 37 (Diabetes with Chronic Complications) under CMS-HCC V28. Its source-labeled community non-dual aged reference coefficient is 0.166. This is not a member total; full contribution depends on hierarchy, cleanup, interactions, member context, and model year. It can also map to HCC 383 (Chronic Ulcer of Skin, Except Pressure, Not Specified as Through to Bone or Muscle) and HCC 298 (Severe Diabetic Eye Disease, Retinal Vein Occlusion, and Vitreous Hemorrhage) when the documentation supports those manifestations.
Quick Facts
HCC Categories
HCC 383, Chronic Ulcer of Skin, Except Pressure, Not Specified as Through to Bone or Muscle
HCC 298, Severe Diabetic Eye Disease, Retinal Vein Occlusion, and Vitreous Hemorrhage
HCC 38, Diabetes with No, Glycemic, or Unspecified Complications
HCC 37, Diabetes with Chronic Complications
RAF Weight Range
0.166 to 0.646
Community, non-dual, aged (V28)
Model
CMS-HCC V28 (PY2026, 100% phase-in)
10 ICD-10 codes map to payment HCCs
How coders write it
Chart notes, problem lists, and queries rarely spell out Diabetes Mellitus (Type 2). The shorthand you will actually see:
Whatever the note calls it, the payment question is the same: how the ICD-10-CM code resolves to a payment HCC.
What HCC category does Diabetes Mellitus (Type 2) map to under V28?
Under CMS-HCC V28, uncomplicated, glycemic, or unspecified diabetes maps to HCC 38, while diabetes with chronic complications maps to HCC 37. Some E11 combination codes also map to manifestation categories: E11.621 maps to HCC 37 and HCC 383, and E11.311 maps to HCC 37 and HCC 298. These are source-backed mapping references, not a member total. Full contribution depends on hierarchy, cleanup, interactions, member context, and model year. Accurate coding still requires the documented diabetes type, manifestation, and treatment plan.
ICD-10 to HCC Mapping
| ICD-10 Code | Description | Billable | HCC Mapping |
|---|---|---|---|
| E11.9 | Type 2 diabetes mellitus without complications | Yes | HCC 38 |
| E11.65 | Type 2 diabetes mellitus with hyperglycemia | Yes | HCC 38 |
| E11.22 | Type 2 diabetes mellitus with diabetic chronic kidney disease | Yes | HCC 37 |
| E11.40 | Type 2 diabetes mellitus with diabetic neuropathy, unspecified | Yes | HCC 37 |
| E11.311 | Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema | Yes | HCC 37 + HCC 298 |
| E11.51 | Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene | Yes | HCC 37 |
| E11.621 | Type 2 diabetes mellitus with foot ulcer | Yes | HCC 37 + HCC 383 |
| E11.69 | Type 2 diabetes mellitus with other specified complication | Yes | HCC 37 |
| E11.21 | Type 2 diabetes mellitus with diabetic nephropathy | Yes | HCC 37 |
| E11.42 | Type 2 diabetes mellitus with diabetic polyneuropathy | Yes | HCC 37 |
Displayed numbers are source-labeled community non-dual aged reference coefficients from CMS-HCC V28, not member totals.
Verify Diabetes Mellitus (Type 2) against the CMS-HCC risk adjustment model files and the CMS ICD-10-CM code set.
Coder workflow notes
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Documentation Tips
Always document the specific type of diabetes (Type 1, Type 2, or secondary), never code 'unspecified diabetes' when the type is known.
Document causal relationships between diabetes and complications (e.g., 'diabetic nephropathy' vs. 'nephropathy in a patient with diabetes').
Use combination codes from E11 for diabetes with complications rather than coding diabetes and complications separately.
Specify laterality for diabetic retinopathy and severity of macular edema when applicable.
Document current HbA1c level and whether hyperglycemia or hypoglycemia is present at the encounter.
Record all active diabetic complications at every encounter, do not rely on problem list carry-forward without provider attestation.
Document the treatment plan including medications, insulin use, and monitoring frequency as part of the documentation review.
MEAT documentation examples for Diabetes Mellitus (Type 2)
These examples organize documentation review using the MEAT review mnemonic for Diabetes Mellitus (Type 2). Follow the applicable coding, encounter, program and payer requirements; these examples do not establish reportability on their own.
MMonitor
“A1c 8.2 percent today, up from 7.4 percent in March; continue quarterly labs.”
“CGM download reviewed: time in range 58 percent, two overnight lows this month.”
“Urine albumin-creatinine ratio 210 mg/g; repeat in three months.”
EEvaluate
“Monofilament exam: sensation absent at bilateral great toes, vibratory sense diminished.”
“Foot exam: 0.4 cm shallow ulcer, left plantar surface, no surrounding cellulitis.”
“Dilated retinal exam reviewed: moderate NPDR with macular edema, right eye.”
AAssess
“Type 2 diabetes with diabetic polyneuropathy, worsening despite gabapentin.”
“T2DM with stage 3a diabetic CKD, stable; A1c above goal.”
“Uncontrolled T2DM with hyperglycemia; adherence barriers discussed.”
TTreat
“Increase metformin to 1000 mg twice daily; recheck A1c in three months.”
“Started empagliflozin 10 mg daily for renal protection.”
“Referred to podiatry for ulcer debridement; wound care instructions given.”
Common Coding Mistakes
Coding E11.9 (without complications) when the patient has documented diabetic complications, always code to the highest specificity.
Failing to link diabetes as the cause of kidney disease, neuropathy, or retinopathy when the provider has documented the causal relationship.
Using E13.- (other specified diabetes mellitus) as a synonym for unspecified diabetes. Verify the documented diabetes type and applicable category.
Missing the opportunity to code diabetic chronic kidney disease (E11.22) alongside the specific CKD stage code.
Not capturing hyperglycemia (E11.65) when the encounter note documents elevated blood glucose or uncontrolled diabetes.
V24 to V28 Changes
V28 reorganized the diabetes hierarchy into HCC 37 (Diabetes with Chronic Complications) and HCC 38 (Diabetes with No, Glycemic, or Unspecified Complications). Both have a source-labeled community non-dual aged reference coefficient of 0.166. Some combination codes also map to manifestation categories: E11.621 (foot ulcer) maps to HCC 37 and HCC 383, whose reference coefficient is 0.646, and E11.311 (retinopathy with macular edema) maps to HCC 37 and HCC 298, whose reference coefficient is 0.336. These are mapping and coefficient references, not a member total. Full contribution depends on hierarchy, cleanup, interactions, member context, and model year. Capture each documented manifestation with the specific combination code, not just the base diabetes code.
| Aspect | V24 (through PY2025) | V28 (PY2026) |
|---|---|---|
| Uncomplicated Type 2 (E11.9) | HCC 19, Diabetes without Complication, RAF 0.105 | HCC 38, Diabetes with No, Glycemic, or Unspecified Complications, RAF 0.166 |
| Chronic complications (E11.22, E11.40, E11.42) | HCC 18, Diabetes with Chronic Complications, RAF 0.302 | HCC 37, Diabetes with Chronic Complications, RAF 0.166 |
| Hyperglycemia (E11.65) | Treated as a complication under HCC 18, RAF 0.302 | Grouped with uncomplicated diabetes under HCC 38, RAF 0.166 |
| Complicated vs. uncomplicated payment gap | Complications nearly tripled the diabetes weight | The listed CNA reference coefficients are equal; member totals depend on the complete model context |
| Diabetic foot ulcer (E11.621) | Maps to HCC 18 and the V24 ulcer category HCC 161 | Maps to HCC 37 and HCC 383; 0.646 is the HCC 383 reference coefficient, not a member total |
These values are community, non-dual, aged code-level coefficient references for each model's payment year, not full member scores. For CMS-HCC V28 PY2026 member scoring with complete context, open the RAF Calculator. No score is shown unless every required source and calculation check passes.
Diabetes Mellitus (Type 2) coding FAQs
Does E11.9 still risk-adjust under V28?
Yes. E11.9 (Type 2 diabetes without complications) maps to HCC 38 with a community, non-dual, aged RAF weight of 0.166 under CMS-HCC V28. The historical V24 CNA references listed here are 0.302 for complicated diabetes and 0.105 for uncomplicated diabetes; the V28 CNA reference is 0.166 for both HCC 37 and HCC 38. These are coefficients, not payments. Complications still matter for the hierarchy and for manifestation categories like HCC 383, just not for the base diabetes weight.
What is the difference between HCC 37 and HCC 38?
HCC 37 is Diabetes with Chronic Complications and HCC 38 is Diabetes with No, Glycemic, or Unspecified Complications. HCC 37 sits above HCC 38 in the V28 hierarchy, so a patient with both a complicated and an uncomplicated diabetes code gets credit for HCC 37 only. Both carry a community, non-dual, aged RAF weight of 0.166 for payment year 2026.
Why does E11.65 map to HCC 38 instead of HCC 37?
V28 treats hyperglycemia as a glycemic status rather than a chronic complication, so E11.65 groups with uncomplicated and unspecified diabetes in HCC 38. Under V24 the same code counted as a complication and paid the higher HCC 18 weight, which is why coders moving from V24 keep expecting it in the complicated category.
Related Conditions
Related references
Sources
Displayed numbers are source-labeled community non-dual aged reference coefficients from CMS-HCC V28, not member totals.
Verified current to CMS-HCC V28, payment year 2026 — last reviewed September 5, 2026.
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