As November’s Diabetes Awareness Month observance highlights prevention and ongoing care, it is also an opportunity to strengthen documentation of Diabetes-related risk. Diabetes can affect multiple organ systems, increase care needs, and contribute to serious complications. Complete, specific documentation helps the care team understand a Member’s current health status and supports accurate risk-adjustment coding.

Capture Factors That Increase Risk

• Identify the Diabetes type and status: Document type 1, type 2, Diabetes due to an underlying condition, drug-induced Diabetes, or other specified Diabetes. Include hyperglycemia or hypoglycemia when present
• Connect Diabetes to its complications: Clearly document associated renal, neurologic, ophthalmic, circulatory, skin, or other manifestations
• Describe severity and specificity: Include details such as site, laterality, stage, edema, gangrene status, or ulcer severity when applicable

Show Active Management

Documentation should reflect the clinical work performed during the encounter. Include relevant glucose or A1C trends, symptoms, medications, treatment response, monitoring, education, referrals, care planning, and follow-up. These details demonstrate that the condition and its complications were assessed and actively managed.

Support Accurate Risk Capture

Select the code category that matches the documented Diabetes type and use combination codes for each documented complication. Add required details, such as the stage of chronic kidney disease or the site, laterality, and severity of an ulcer. Use uncomplicated Diabetes code only when no complication is documented.

Diabetes Coding Examples

The following examples show how specific documentation supports appropriate code selection and helps represent Diabetes-related risk accurately.

During Diabetes Awareness Month and throughout the year, document the full clinical picture—not Diabetes alone. Clear documentation of type, status, complications, severity, and active management supports coordinated care and helps ensure the Member’s risk is represented accurately.