A patient presents to the clinic for follow up of type 2 diabetes.

In the CMS-HCC model, diabetes categories are hierarchical, meaning you capture the highest supported diabetes HCC for the year, not multiple diabetes HCCs simultaneously. Type 2 diabetes with peripheral neuropathy represents achronic diabetic complication, so it maps toHCC 18 (Diabetes with Chronic Complications)rather than HCC 19 (without complications) or HCC 17 (acute complications). COPD is documented as present and clinically relevant (even without an exacerbation) and therefore maps toHCC 111 (Chronic Obstructive Pulmonary Disease)when it is assessed/managed as part of the visit. “History of depression, stable” does not necessarily meet the threshold forHCC 58, which is reserved for specific serious psychiatric diagnoses (e.g., major depressive disorder, bipolar disorder, paranoid disorders). A general “depression” history, especially if not specified as major depressive disorder and not actively addressed, often will not support HCC 58 capture. Therefore, the visit captures HCC 18 and HCC 111 only.