Precision Pays: How Specific Diabetes Complications Improve RAF Scores Under CMS’s New Model

Diabetes Complication Coding: Why Specificity Is Everything

If your coding or documentation still leans on broad labels like E11.69 (Type 2 diabetes with other complication) — it’s time for a rethink.

Under CMS’s newer model, only clinically specific complications will map to an HCC — and many general codes no longer qualify for risk adjustment at all.

The good news? When documented correctly, specific diabetes complications can actually increase RAF scores — meaning more accurate reimbursement for higher-risk members.

Real Example: How a Simple Coding Shift Improves RAF

Let’s look at how updating your diabetes coding impacts risk scores:

  • Old Code (V24 Model):
    - E11.69     – Type 2 diabetes with other complication
    - RAF Score: 0.318

  • Updated Code (V28 Model):
    - E11.22     – Type 2 diabetes with chronic kidney disease
    - RAF Score: 0.388

Key takeaway: Replacing general codes like E11.69 with specific diagnoses such as E11.22 doesn’t just improve compliance — it increases the RAF by 0.07, which can significantly impact revenue when multiplied across hundreds or thousands of enrollees.

Clinical Coding Tip: Document to Defend

To correctly code specific complications — and to survive audit scrutiny — your documentation needs to reflect clinical precision. Here’s how:

For CKD-related Diabetes (E11.22):

  • GFR or eGFR results showing renal impairment

  • Notation of CKD stage in the progress note

  • Medication list with nephrology-focused management (e.g., ACE inhibitors)

  • Referral or notes from a nephrologist supporting the diagnosis

For Retinopathy or Neuropathy:

  • Results of ophthalmology or neurology consults

  • Mention of visual changes, nerve symptoms, or treatment plans

  • Fundus photography or EMG if applicable

Use each visit to update or reaffirm complication activity. A static problem list isn’t enough.

What to Stop Doing Now

  • Using E11.69 as a catch-all

  • Leaving complications undocumented

  • Assuming lab values alone are sufficient without provider interpretation

  • Ignoring referrals and consults that justify specific coding

Why This Change Matters

  1. More Accurate Payments
    CMS’s risk scores now better align with the real clinical burden — but only if documentation reflects true complexity.

  2. Audit Protection
    Vague or unsupported diagnoses are top audit triggers. Specificity with lab data, consults, and clear narratives shields you from retroactive recoupment.

  3. Better Patient Tracking
    Specific codes make it easier to monitor disease progression, coordinate referrals, and flag patients for chronic care programs.

Coding with Confidence: What You Can Do

  • Train providers to document complications, not just “diabetes.”

  • Create cheat sheets with ICD-10 mappings for common diabetes complications (e.g., CKD = E11.22, retinopathy = E11.319).

  • Set up query templates in your EHR to prompt for CKD stage, nephrology involvement, or A1c trends.

  • Review EHR problem lists to identify outdated or vague codes.

Final Thoughts: Specificity is the New Standard

Risk adjustment is evolving — and CMS is rewarding those who evolve with it. Under the updated model, generalized diabetes codes are out, and specific, evidence-backed complications are in.

If you’re not capturing diabetes with CKD, retinopathy, or neuropathy accurately, you're not just risking compliance — you’re losing out on rightful reimbursement.

Precision in coding isn’t optional anymore — it’s your path to smarter payment, stronger audit defense, and better care.

Need help auditing your diabetes risk codes or training your providers for V28 accuracy? Contact us