Organizations are not required to identify or confirm the diagnosis of diabetes through medical record review; only the hypertension diagnosis must be confirmed. Only administrative data should be used to assign the diabetes flag. The intent of the flag is to determine the appropriate BP threshold to use for the member during numerator assessment because the threshold for members with diabetes is different from the threshold for members without diabetes.
The only exception is if the member is flagged as a diabetic but medical record evidence contains information that classifies the member as a valid data error. To meet criteria as a valid data error, the medical record must contain no evidence of diabetes and include a notation that refutes the diagnosis, as described in Substituting Medical Records in the Guidelines for Calculations and Sampling. In this case, the diabetes flag may be changed to “not diabetic”, but the member may not be removed from the sample.
HEDIS 2015