Journal of Diabetes and Its Complications 31 (2017) 1007–1013

Contents lists available at ScienceDirect

Journal of Diabetes and Its Complications

j o u r n a l h o m e p a g e : W W W. J D C J O U R N A L . C O M

Diabetes Complications Severity Index (DCSI)—Update and

ICD-10 translation
William P. Glasheen a,⁎, 1, Andrew Renda b, 2, Yanting Dong c, 3
a
Humana Inc., Clinical Analytics, 101 S. Fifth Street, 11th Floor, Louisville, KY 40202, USA
b
Humana Inc., Office of the Chief Medical Officer,500 West Main Street, 14th Floor, Louisville, KY 40202, USA
c
Humana Inc., Clinical Analytics, Louisville, KY, USA

a r t i c l e i n f o a b s t r a c t

Article history: Aims: The Diabetes Complications Severity Index (DCSI) converts diagnostic codes and laboratory results into
Received 22 December 2016 a 14-level metric quantifying the long-term effects of diabetes on seven body systems. Adoption of the
Received in revised form 16 February 2017 International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) necessitates
Accepted 17 February 2017 translation from ICD-9-CM and creates refinement opportunities.
Available online 14 March 2017
Methods: ICD-9 codes for secondary and primary diabetes plus all five ICD-10 diabetes categories were incorporated
into an updated tool. Additional modifications were made to improve the accuracy of severity assignments.
Keywords:
Diabetes
Subjects: The tools were tested in a Medicare Advantage population.
Risk adjustment Results: In the type 2 subpopulation, prevalence steadily declined with increasing score according to the updated
ICD-10 DCSI tool, whereas the original tool resulted in an aberrant local prevalence peak at DCSI = 2. In the type 1
Disease management subpopulation, score prevalence was greater in type 1 versus type 2 subpopulations (3 versus 0) according to both
Population health instruments. Both instruments predicted current-year inpatient admissions risk and near-future mortality, using
either purely ICD-9 data or a mix of ICD-9 and ICD-10 data.
Discussion: While the performance of the tool with purely ICD-10 data has yet to be evaluated, this updated tool
makes assessment of diabetes patient severity and complications possible in the interim.
© 2017 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction systems or dimensions. 3 The creators of DCSI matched International

The Centers for Disease Control (CDC) estimated that in 2012 more
than 9% of the population had diabetes, resulting in annual healthcare
expenditures 2.3 times higher than expenditures for people without
diabetes. 1 Much of the cost of treating diabetes comes from the
long-term effects of the disease on various body systems. Poor
management of the disease and the resultant end-organ damage lead
to an increase in hospital admissions, which account for more than
40% of costs attributable to diabetes. 2
To help healthcare organizations better allocate resources for
population health improvement and disease management, Young et
al. developed a scoring system for diabetes complications — the
Diabetes Complications and Severity Index (DCSI). The DCSI quantifies
the presence and severity of complications according to seven body
Conflict of interest: The authors have no conflict of interest other than full–time
employment with Humana Inc.
⁎ Corresponding author.
E-mail addresses: wglasheen@humana.com (W.P. Glasheen),
arenda1@humana.com (A. Renda), ydong@humana.com (Y. Dong).
1
Tel.: +1 804 346 9996.
2
Tel.: +1 502 476 0114.
3
Tel.: +1 502 476 9645.
Classification of Diseases-9-CM (ICD-9-CM) diagnostic codes to
diabetes complications occurring in each body system and assigned
a severity rating of 1 or 2 to each code. Abnormal laboratory results
were incorporated into the Nephropathy dimension and assigned 1 or
2 points. The DCSI developers specified that each body system be
scored 0 (no complications), 1 (at least one complication but no
severe complications), or 2 (at least one severe complication). Thus,
the possible range of summed body system scores was 0 to 13 (a score
of 2 was not possible for the Neuropathy dimension). Fourteen levels
of diabetes severity is significantly more granular than the three
categories captured in the current Hierarchical condition Categories
(HCC) model used by the Centers for Medicare and Medicaid Services
(CMS) to make risk-adjusted payments to Medicare Advantage
plans. 4 Young et al. validated the DCSI by showing the score to be
predictive of both hospital admissions and mortality within a 4-year
time span for patients with diabetes, after adjustment for other risk
factors. 3 Others have shown a monotonically increasing relationship
between DCSI score and total healthcare resource utilization and costs
in a Medicare Advantage population. 5,6
In October of 2015, the U.S. healthcare system transitioned from
ICD-9 CM to ICD-10 CM. For users of the DCSI tool, this created an
immediate need for an ICD-10 translation. The expansion from 14,025

http://dx.doi.org/10.1016/j.jdiacomp.2017.02.018
1056-8727/© 2017 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
1008 W.P. Glasheen et al. / Journal of Diabetes and Its Complications 31 (2017) 1007–1013
to 68,823 codes in ICD-10 7 also created more nuanced and up-to-date
categorization and severity assessment. Furthermore, since the DCSI
instrument uses a prior 12-month interval of claims data, the ICD-9
and ICD-10 scoring systems needed to match as closely as possible to
enable valid analyses of data traversing the transition date. This meant
that any modification to the original instrument needed to be made
simultaneously with the creation of an ICD-10-compatible version.
We saw three obvious opportunities to make refinements in the ICD-9
scoring scheme for DCSI before proposing an ICD-10 scheme.
The first opportunity was to recognize that the updated ICD-10
diagnostic code system forces greater specificity in defining diabetes
type. ICD-9 used the code 250.x for primary diabetes and 249.x for
secondary diabetes (caused by a drug, chemical, or medical condition
other than diabetes). For both primary and secondary diabetes, a 4th
digit specifies diabetes complication. For primary diabetes a 5th digit
specifies either (a) type I [juvenile type] or (b) type II or unspecified
type. In contrast, ICD-10 uses five distinct diabetes code families:
E08.x, diabetes with underlying conditions; E09.x, drug-/chemical-
induced diabetes; E10.x, type 1; E11.x, type 2; and E13.x, other. The
original DCSI scoring system made no accommodation for secondary
diabetes, i.e., ICD-9 code 249.x was not included. Thus, the first task for
creating an ICD-10 translation was to devise a DCSI instrument based
on ICD-9 with secondary diabetes included.
Another opportunity for refinement was the somewhat limited scope
of renal tests considered in scoring the Nephrology dimension and the lack
of a list of Logical Observation Identifiers Names and Codes (LOINC) for the
included laboratory tests, an omission that has become significant because
of the expansion in available lab codes since creation of the DCSI.
A third refinement opportunity involved the “weighting” of renal
disease codes. Young et al. assigned 2 points to all Chronic Kidney
Disease (CKD) (585.x) codes, regardless of estimated glomerular
filtration rate (eGFR) laboratory results. Given that CKD stage 1 is
associated with virtually normal eGFR values, counting all CKD codes
as representing equivalent severity puts relatively healthy patients in
the same category as dialysis patients in need of a kidney transplant.
1.1. Objective
The work described herein was intended to meet the following
objectives: (1) expansion and refinement of the ICD-9 scoring system
for DCSI, as published by Young et al., (2) creation of an ICD-10 DCSI
scoring system, (3) assessment of the comparability of the original
DCSI, the ICD-9-based updated DCSI, and the ICD-10-based DCSI, and
(4) validation of the new scoring schemes by testing their association
with hospital admissions and short-term mortality. This research did
not receive any specific grant from funding agencies in the public,
commercial, or not-for-profit sectors.
2. Subjects
The original DCSI instrument and the updated DCIS instrument
were tested in a Medicare Advantage population.
3. Materials and methods
3.1. Selection and organization of diagnostic codes
The primary products of this initiative were seven ICD-9 and
ICD-10 code and scoring tables specific to body system, a LOINC Code
table for laboratory tests within the Nephropathy dimension, and
modifications to the laboratory test results scoring system (incorpo-
rated into the Nephropathy code table). The code tables have been
included in Appendices (see online Supplementary Materials).
The primary tools used to identify codes were icd9data.com for the
ICD-9 diagnostic codes and icd10data.com for the ICD-10 diagnostic
codes, matched resources with suggested crosswalks between ICD-9 and
ICD-10. These two sites are owned and operated by Alkaline Software and
are supported by limited advertising. Through an independent thorough
search of these sites for all possible diabetes-related complications, direct
or otherwise, each code in the original DCSI publication was verified or
reassigned, and additional codes were incorporated.
The seven-category structure for diabetes complications (Retinopathy,
Nephropathy, Neuropathy, Cerebrovascular, Cardiovascular, Peripheral
Vascular Disease [PVD] and Metabolic) of the original DCSI was preserved,
but retinopathy dimension was re-labeled as Ophthalmic. Within each
dimension, the same presence/severity levels (0, 1, or 2 points) for a
complication were preserved, as was the practice of assigning a dimension
score based on the most severe complication level reflected by one or
more claims in the time window.
The first modification of the instrument was designed to register
diabetes-related complications regardless of the diabetes type
specified. The primary method used to select complication codes for
each of the seven DCSI dimensions was through the 4th digits in code
families for secondary and primary diabetes in ICD-9 (249.x and
250.x)and ICD-10 (E08.x, E09.x, E10.x, E11.x, and E13.x). This was true
for the Metabolic, Nephropathy, Neuropathy, Ophthalmic, and PVD
dimensions. As in the original instrument, other complication codes
not captured by diabetes code categories were included. In some cases
the reference to diabetes was explicit; in other cases it was not.
The second set of modifications had to with renal test results. A
somewhat different set of laboratory tests, including the addition of
eGFR, was incorporated into the scoring scheme for the Nephropathy
dimension. A score of 1 or 2 was assigned to each test results
threshold. Only the most recent valid test result of each test type in
the time window for a particular analysis was considered. As in the
original DCSI scheme, the points assigned to the Nephropathy
dimension would be the highest of the points assigned to any
complication or test result. A list of appropriate LOINC codes (see
Appendix B), not available in the original publication, was generated
from hipaaspace.com. This fee-based site provides several look-up
services for providers and payers, including a LOINC Lookup &
Verification Service that includes a “Similar LOINC Codes” feature.
Some point values associated with the diabetes complications
were changed in the updated model, most notably for specific stages
of CKD. Mild to moderate CKD (stages 1–3) was allocated 1 point,
while severe CKD (stages 4, 5) was allocated 2 points. In the original
DCSI, 2 points were assigned to any CKD diagnosis regardless of stage.
Additionally, ICD-10 created an opportunity to improve the granu-
larity of the Metabolic dimension by assigning 1 or 2 according to
whether there is coma in the presence of hyperosmolarity, ketoaci-
dosis, or hypoglycemia. See Appendix A-7.
In summary, the primary departures from the work by Young et al.
were the following: 1) the inclusion of secondary diabetes from ICD-9
and its equivalents in ICD-10; 2) the incorporation of eGFR results into
the set of renal laboratory results and the provision of a LOINC list; 3) the
splitting of chronic kidney disease (CKD) diagnosis codes and laboratory
test thresholds into two levels of severity; and 4) the splitting of the
Metabolic dimension into two levels of severity (ICD-10 only).
3.2. Process
The same biomedical engineer who had written SAS code for the
original DCSI instrument also performed the research supporting the
updated instruments. The new code sets were reviewed by a
physician who was familiar with administrative data and had helped
maintain another proprietary diagnostic classification system. A
second physician then created code scoring tables for each of the
DCSI dimensions, with codes separately listed for the original DCSI,
the updated DCSI applied to ICD-9, and the updated DCSI applied to
ICD-10. The final tabular presentations were reviewed by a team of
the two original researchers and a medical writer for consistency with
each other and with the original lists of codes. A SAS program was
 W.P. Glasheen et al. / Journal of Diabetes and Its Complications 31 (2017) 1007–1013 1009

created that reflected the ICD-9 scoring modifications and the new were applied. Demographics were very similar. However, the
ICD-10 scoring system. percentage of patients categorized as having secondary diabetes
rose and primary diabetes types proportionally decreased in the later
3.3. Sample selection and classification time window, which included some ICD-10 coding. Data in intermediate
time windows (not shown) demonstrated a consistent trend of
The old and new scoring systems were tested in the Humana Medicare increasing prevalence of secondary diabetes and corresponding declines
Advantage population and included people who were continuously in primary diabetes. This suggests that providers of care are sometimes
enrolled for each of two 12-month time windows and who had one or coding diabetes type differently as they transition to ICD-10.
more claims during the time window with one of the following ICD-9 code Table 2 illustrates DCSI dimension-specific score distributions (0 to
categories, all of which are diabetes-specific or include codes for diabetes 2) for type 2 and for type 1 patient subpopulations. Within each
complications: 249.x, 250.x, 357.2, 362.0×, 366.41, or 648.4×. Individuals diabetes type the table presents results reflective of a transition from
younger than 18 or older than 110 years of age during the time window the original DCSI model to the updated DCSI model in the latest 1-year
and individuals with dual eligibility (Medicaid and Medicare) were time window of all ICD-9 diagnostic data and then the transition to the
excluded. The initial time window was the latest 1-year window where updated DCSI model in a time period containing some ICD-10 data.
ICD-9 codes were used exclusively: October 2014–September 2015. The Table 2 further reveals that code distributions in five of the seven
original DCSI scoring system and the modified ICD-9-based system were DCSI Dimension results (Ophthalmic, Neuropathy, Cerebrovascular,
applied separately to this population. Cardiovascular, and Peripheral Vascular Disease or PVD) remained
Results were computed for a second time window (February largely unchanged across the three combinations of time and DCSI
2015–January 2016). The revised ICD-9-based system and the version within diabetes type subpopulations. The most dramatic
ICD-10-based system were jointly applied by the new program (the changes across DCSI model outputs were observed in the Nephrop-
updated DCSI) to this additional population. For claims data past athy and Metabolic dimensions, both for type 1 and for type 2
September 30, 2015, one of the following ICD-10 code categories subpopulations. With the updated DCSI instrument, patient prevalence
was used to identify individuals with diabetes: E08.x, E09.x, E10.x, monotonically decreased as Nephropathy level increased from 0 to 1 to
E11.x, E13.x, O24.0×, O24.1×, O24.3×, O24.8×, and O24.9×. (Note, 2, whereas the original DCSI suggested a marked prevalence dip at
the O** series codes included refer to pregnancy with diabetes, not Nephropathy level 1. The updated DCSI model added granularity at level
gestational diabetes, and do not have sub-codes related to diabetes 1 in the Metabolic dimension in the final population, where there were
complications.) ICD-10 codes in some cases differentiating between metabolic
Diabetes type was assigned as type 2 (5th digit of 250.x as 0 or 2, or complications with and without coma. The prevalence was nonzero
E11.x); type 1 (5th digit of 250.x as 1 or 3, or E10.x); secondary (249.x, for Metabolic level 1 in the supposedly all ICD-9 window, demonstrating
E08.x, E09.x, E13.x); or other (i.e., identified only on the basis of pregnancy the existence of a few ICD-10 codes coming in before October 1, 2015.
with diabetes or a diabetes-related complication). Where there was more This Metabolic level 1 prevalence increased in the second time window,
than one type specified in the patient claims, secondary trumped type 1, which reflects ICD-10 data from October 1, 2015 and forward.
type 1 trumped type 2 and type 2 trumped other. Figs. 1 (type 2 diabetes) and 2 (type 1 diabetes) simultaneously
illustrate the relationship between DCSI score and population
3.4. Comparison of and validation of scoring systems prevalence. The updated DCSI demonstrated a steadily decreasing
prevalence of complication severity in the type 2 subpopulation,
Separate results for type 1 and type 2 are presented for three whereas the original DCSI resulted in an aberrant local prevalence
combinations of time window and ICD version, as reflected in the peak at DCSI = 2. According to the updated DCSI, the most prevalent
column headings for Tables 2 and 3. No analyses were conducted for score was 3 points greater in the type 1 versus type 2 subpopulation
people with secondary or unspecified (other) diabetes because of the (3 versus 0). In the type I diabetes subpopulation a skewed Pareto-like
small sizes of these subpopulations. The dimension-specific preva- prevalence was exhibited, peaking at DCSI = 3 regardless of DCSI
lence of each of the three DCSI scores (0–2) was computed. As a version or time period.
preliminary validation of the updated DCSI instrument, the associa-
tion of DCSI score with current-year hospital admissions and with Table 1
short-term mortality was assessed. Simple linear regression using 10 Population demographics, two periods (percentage of total).
binary variables for nonzero DCSI scores as covariates modeled the Characteristic Oct. 2014 to Sept. 2015 Feb. 2015 to Jan. 2016
difference in admissions per 1000 for the current time 1-year window
TOTAL (n) 784,355 820,299
relative to admissions for those with a DCSI = 0. The significance of Diabetes Type
coefficients was tested by two-tailed t-tests. Secondary 1.58% 6.08%
A robust Poisson multivariate regression model was constructed to Type 1 8.97% 8.28%
assess the relationship of DCSI score with mortality in the 4-month Type 2 89.45% 85.64%
Sex
period starting with the final enrollment month (September– Female 51.28% 50.99%
December 2015 for the first population and January–April 2016 for Male 48.72% 49.01%
the second population). Because of the difference in mortality Age (years)
patterns that would be expected in younger and older adults, 18–44 0.73% 0.75%
45–64 14.27% 15.01%
mortality was assessed in a subset of patients who were 65 and
65–74 46.95% 47.17%
older during the time window. To adjust for demographic and clinical 75–84 29.56% 28.96%
factors, the following covariates were included in the mortality model 85–94 8.07% 7.72%
in addition to DCSI score (represented as 10 categorical variables): sex 95–110 0.42% 0.39%
(reference, female); race (reference, white); age group (reference, Race
Asian 1.08% 1.26%
65–69 years); and diabetes type (reference, type 2). Black 17.15% 17.89%
Hispanic 1.89% 1.94%
4. Results Native American 0.26% 0.27%
Other 1.57% 1.72%
White 77.52% 76.36%
Table 1 provides perspective on the two 1-year panels of
Unknown 0.54% 0.56%
continuously enrolled populations to which the coding schemes
1010 W.P. Glasheen et al. / Journal of Diabetes and Its Complications 31 (2017) 1007–1013

Table 2
Score distributions by dimension.

DCSI Dimension Type 2 Diabetes Type 1 Diabetes

Young DCSI Updated DCSI Updated DCSI Young DCSI Updated DCSI Updated DCSI
Score (ICD-9) Oct. 2014– (ICD-9) Oct. 2014– (ICD-9/10) Feb. 2015– Score (ICD-9) Oct. 2014– (ICD-9) Oct. 2014– (ICD-9/10) Feb. 2015–
Sept. 2015 Sept. 2015 Jan. 2016 Sept. 2015 Sept. 2015 Jan. 2016

Total (n) – 701,609 701,609 702,478 – 70,364 70,364 67,953

0 85.96% 85.69% 86.27% 0 66.11% 65.51% 66.91%
Retinopathy/Ophthalmic
1 10.19% 10.44% 9.84% 1 22.06% 22.56% 21.13%
(% total)
2 3.85% 3.88% 3.89% 2 11.83% 11.93% 11.95%
0 66.12% 58.31% 58.82% 0 51.37% 44.86% 45.63%
Nephropathy (% total) 1 4.14% 30.94% 32.16% 1 5.73% 33.67% 36.43%
2 29.74% 10.75% 9.01% 2 42.90% 21.47% 17.93%
0 66.50% 66.50% 67.86% 0 40.88% 40.88% 43.83%
Neuropathy (% total)
1 33.50% 33.50% 32.14% 1 59.12% 59.12% 56.17%
0 86.75% 86.75% 87.32% 0 80.77% 80.77% 82.04%
Cerebrovascular (% total) 1 1.09% 1.09% 1.08% 1 1.40% 1.40% 1.40%
2 12.16% 12.16% 11.61% 2 17.83% 17.83% 16.56%
0 52.47% 52.47% 52.76% 0 39.73% 39.72% 41.04%
Cardiovascular (% total) 1 17.83% 17.83% 17.05% 1 19.30% 19.30% 18.81%
2 29.70% 29.71% 30.19% 2 40.97% 40.98% 40.16%
0 79.61% 79.60% 80.47% 0 62.62% 62.61% 64.43%
Peripheral Vascular
1 16.74% 16.74% 16.21% 1 25.67% 25.68% 25.46%
Disease (% total)
2 3.66% 3.66% 3.32% 2 11.71% 11.71% 10.11%
0 99.24% 99.23% 98.74% 0 95.14% 95.13% 93.43%
Metabolic (% total) 1 0.00% 0.00% 0.68% 1 0.00% 0.01% 3.35%
2 0.76% 0.76% 0.58% 2 4.86% 4.86% 3.22%

DCSI, Diabetes Complications Severity Index.

Figs. 1 and 2 also show the relationship between DCSI score and
utilization as reflected by the increase in current-year inpatient
admissions per 1000 associated with each nonzero score. In both type
1 and type 2 diabetes, increasing values of DCSI were associated with
increasingly larger differences in number of admissions per 1000,
compared with admissions/1000 for the DCSI = 0 subgroup, signif-
icant in all cases at the P b 0.05 level.
Table 3 illustrates the results of the robust Poisson regression
modeling designed to assess the magnitude of the effect of DCSI score
on short-term mortality, after adjusting for other predictors, in a 65
and older subset. In each combination of DCSI version and time
window, the relative risk (RR) of mortality associated with different
demographic factors followed expected patterns. RR steadily in-
creased as DCSI score increased. Comparing the updated with the
original DCSI for ICD-9 data shows that RRs based on the updated
scoring had fewer overlapping 95% confidence intervals and they
appeared later (not until DCSI = 8) as score increased. This suggests
that the updated model may provide better discrimination between
severity levels. Discrimination among the lower score levels (up to
DCSI = 6) was preserved in application of the updated model to the
mix of ICD-9 and ICD-10 data.
5. Discussion
The original DCSI model created by Young et al. was an innovative
and highly practical tool for the diabetes care community. The
Charlson Comorbidity Index (CCI) had already been developed and
validated to permit control for disease severity and comorbidity using

25% 1,500

Increase in Inpatient Admissions per 1,000

20% 1,200 Compared with DCSI = 0
Percent of Population

15% 900

10% 600

5% 300

0% 0
0 1 2 3 4 5 6 7 8 9 10+
DCSI Score

Young DCSI (ICD-9), Oct2014-Sep2015 Updated DCSI (mixed ICD9/10), Feb2015-Jan2016 Updated DCSI (modified ICD-9), Oct2014-Sep2015
Young DCSI (ICD-9), Oct2014-Sep2015 Updated DCSI (mixed ICD9/10), Feb2015-Jan2016 Updated DCSI (modifed ICD-9), Oct2014-Sep2015

Fig. 1. Prevalence and change in current-year admission risk by DCSI score; type 2 diabetes. NOTE: The intercept value for the admissions risk model, which is equivalent to
admissions per 1000 for individuals with DCSI = 0, was 44.0 per 1000 (Young), 44.6 (updated DCSI, October 2014–September 2015), and 42.5 (updated DCSI, February 2015–
January 2016).
 W.P. Glasheen et al. / Journal of Diabetes and Its Complications 31 (2017) 1007–1013 1011

Young DCSI (ICD-9), Oct2014-Sep2015 Young DCSI (ICD-9), Oct2014-Sep2015

Young DCSI Cumulative Cumulative Parameter Standard
Frequency Percent Variable DF t Value Pr > |t|
Score Frequency Percent Estimate Error Adj R-Square
0 6,141 8.73% 6,141 8.73% --- 0 0.1404
1 7,592 10.79% 13,733 19.52% DCSI_01 1 40 14.9 2.70 0.0069
2 9,274 13.18% 23,007 32.70% DCSI_02 1 110 14.3 7.69 <.0001
3 9,785 13.91% 32,792 46.60% DCSI_03 1 172 14.2 12.18 <.0001
4 9,272 13.18% 42,064 59.78% DCSI_04 1 262 14.3 18.28 <.0001
5 9,127 12.97% 51,191 72.75% DCSI_05 1 423 14.4 29.49 <.0001
6 7,055 10.03% 58,246 82.78% DCSI_06 1 534 15.2 35.18 <.0001
7 5,602 7.96% 63,848 90.74% DCSI_07 1 797 16.1 49.62 <.0001
8 3,261 4.63% 67,109 95.37% DCSI_08 1 952 18.8 50.53 <.0001
9 2,083 2.96% 69,192 98.33% DCSI_09 1 1,230 22.1 55.76 <.0001
10+ 1,172 1.67% 70,364 100.00% DCSI_10+ 1 1,692 27.7 61.01 <.0001
Intercept Intercept 1 73.8 11.1 6.65 <.0001

Updated DCSI (modified ICD-9), Oct2014-Sep2015 Updated DCSI (modified ICD-9), Oct2014-Sep2015
Young DCSI Cumulative Cumulative Parameter Standard Adj R-Square
Frequency Percent Variable DF t Value Pr > |t|
Score Frequency Percent Estimate Error 0.1522
0 5,459 7.76% 5,459 7.76% --- 0
1 8,349 11.87% 13,808 19.62% DCSI_01 1 35 15.0 2.34 0.0191
2 10,072 14.31% 23,880 33.94% DCSI_02 1 103 14.5 7.08 <.0001
3 10,491 14.91% 34,371 48.85% DCSI_03 1 177 14.4 12.28 <.0001
4 9,989 14.20% 44,360 63.04% DCSI_04 1 280 14.5 19.26 <.0001
5 8,914 12.67% 53,274 75.71% DCSI_05 1 450 14.8 30.33 <.0001
6 6,757 9.60% 60,031 85.31% DCSI_06 1 586 15.7 37.25 <.0001
7 4,847 6.89% 64,878 92.20% DCSI_07 1 875 17.0 51.30 <.0001
8 2,842 4.04% 67,720 96.24% DCSI_08 1 1,045 20.0 52.32 <.0001
9 1,684 2.39% 69,404 98.64% DCSI_09 1 1,351 24.1 56.11 <.0001
10+ 960 1.36% 70,364 100.00% DCSI_10+ 1 1,831 30.2 60.55 <.0001
Intercept Intercept 1 73.6 11.7 6.30 <.0001

Updated DCSI (ICD-10), Feb2015-Jan2016 Updated DCSI (ICD-10), Feb2015-Jan2016 Adj R-Square
Young DCSI Cumulative Cumulative Parameter Standard 0.1389
Frequency Percent Variable DF t Value Pr > |t|
Score Frequency Percent Estimate Error
0 5,837 8.59% 5,837 8.59% --- 0
1 8,550 12.58% 14,387 21.17% DCSI_01 1 26 13.5 1.91 0.0562
2 10,145 14.93% 24,532 36.10% DCSI_02 1 90 13.0 6.92 <.0001
3 10,422 15.34% 34,954 51.44% DCSI_03 1 170 13.0 13.10 <.0001
4 9,784 14.40% 44,738 65.84% DCSI_04 1 256 13.1 19.50 <.0001
5 8,352 12.29% 53,090 78.13% DCSI_05 1 428 13.5 31.58 <.0001
6 6,090 8.96% 59,180 87.09% DCSI_06 1 535 14.5 36.81 <.0001
7 4,322 6.36% 63,502 93.45% DCSI_07 1 778 15.9 48.83 <.0001
8 2,431 3.58% 65,933 97.03% DCSI_08 1 949 19.2 49.54 <.0001
9 1,323 1.95% 67,256 98.97% DCSI_09 1 1,268 24.2 52.50 <.0001
10+ 697 1.03% 67,953 100.00% DCSI_10+ 1 1,705 31.8 53.61 <.0001
Intercept Intercept 1 65.6 10.4 6.32 <.0001

Fig. 2. Prevalence and change in current-year admission risk by DCSI score; type 1 diabetes. NOTE: The intercept value for the admissions risk model, which is equivalent to
admissions per 1000 for individuals with DCSI = 0, was 73.8 per 1000 (Young), 73.6 (updated DCSI, October 2014–September 2015), and 65.6 (updated DCSI, February 2015–
January 2016).

ICD-9 diagnoses from administrative databases. 8,9 The DCSI provides a
diabetes-specific alternative. The DCSI is derived from a quantitative
and comprehensive assessment of seven body systems that can be
affected by diabetes complications. In addition to giving the total score
credibility, this multidimensional approach facilitates clinical under-
standing, provides more useful patient stratification for population
health management and has myriad predictive modeling applications.
The transition to an ICD-10 world was the perfect opportunity to
improve the ability of DCSI to reflect the nature of the disease. Similar
patterns of score prevalence and admissions changes suggested
comparable performance between the original and updated DCSI
and between eras of ICD-9 and mixed ICD-9/10 data. Additionally, the
updated model appears to have corrected an aberrant local prevalence
peak when applied to patients with type 2 diabetes.
Prior to the present study, only one validation of the DCSI or a DCSI
variant 10 has been published since the original publication by Young
et al. Chang and colleagues created an adapted DCSI tool by removing
laboratory data and validated it in a type 2 diabetes population with
coverage under Blue Cross Blue Shield plans (mean age, 59 years). As
in the present study, they found the resulting score to be positively
associated with number of hospitalizations over a 4-year period. A
small number of publications have reported on use of the DCSI to
better understand diabetes populations. 6,11–14 The refinements and
the ICD-10 translation described herein may help researchers in the
current coding era build on this small body of research.
The results of applying the updated DCSI have interesting
implications. Modeling near-term mortality suggested that after
adjustment for DCSI and demographics, autoimmune (type 1) versus
metabolic (type 2) root cause is relatively unimportant (type 1 range
of RR values, 1.05–1.08), while the “secondary” nature of secondary
diabetes matters more (secondary range of RR values, 1.23–1.50). The
new DCSI requires more specific coding with respect to secondary
versus primary diabetes, but as a whole achieves adequate
comparability between ICD-9- and ICD-10-based DCSI scores in
this regard. The most common DCSI score was 3 points higher
in the type 1 subpopulation than in the type 2 subpopulation.
That likely reflects the juvenile versus adult onset pattern of type 1
versus type 2 and the impact of time with the disease. As coding
practices improve to align with the five diabetes code families of
ICD-10 and more data accumulate, additional interesting findings can
be expected.
Neither the original model nor the DCSI version presented here
includes all possible complications or comorbidities associated with
diabetes. Inclusion and exclusion of any diabetes-related condition,
such as dermatologic manifestations, were based on whether such
conditions were reflected in other body systems already included and
whether such clinical manifestations were primarily acute or chronic.
Given that there is a whole category for Peripheral Vascular Disease, the
exclusion of dermatologic manifestations is defensible. Furthermore, a
strength of the DCSI tool is the exclusion of diagnosis codes that could be
influenced by physician or patient treatment propensities; thus, the
codes for amputation (Z89.x, acquired absence of limb) are excluded.
Further consideration of dermatologic and other manifestations is,
however, appropriate. For now, parsimony trumps complexity.
1012 W.P. Glasheen et al. / Journal of Diabetes and Its Complications 31 (2017) 1007–1013

Table 3
Mortality regression models.

CHARACTERISTIC Young DCSI (ICD-9) Oct. 2014–Sept. 2015 Updated DCSI (ICD-9) Oct. 2014–Sept. 2015 Updated DCSI (ICD-9/10) Feb. 2015–Jan. 2016

RR Low 95% CL High 95% CL RR Low 95% CL High 95% CL RR Low 95% CL High 95% CL

SEX
Female − − −
Male 1.23 1.18 1.28 1.23 1.19 1.28 1.24 1.19 1.29
AGE GROUP
65–69 − − −
70–74 1.18 1.10 1.26 1.18 1.10 1.27 1.16 1.09 1.24
75–79 1.47 1.37 1.57 1.47 1.37 1.58 1.47 1.37 1.56
80–84 2.02 1.88 2.17 2.03 1.89 2.18 1.98 1.85 2.11
85–89 2.96 2.75 3.19 2.97 2.76 3.20 2.85 2.65 3.05
90–94 4.79 4.39 5.22 4.81 4.41 5.24 4.63 4.27 5.03
95–110 7.43 6.53 8.45 7.53 6.62 8.56 6.97 6.13 7.93
RACE
White − − −
Asian 0.45 0.33 0.60 0.46 0.34 0.62 0.60 0.47 0.75
Black 0.73 0.69 0.77 0.73 0.69 0.78 0.72 0.68 0.76
Hispanic 0.57 0.48 0.67 0.59 0.50 0.69 0.58 0.50 0.68
Native American 1.20 0.82 1.74⁎ 1.18 0.81 1.72⁎ 0.83 0.55 1.25⁎
Other 0.46 0.36 0.59 0.48 0.38 0.61 0.62 0.51 0.74
Unknown 0.56 0.36 0.88 0.57 0.36 0.89 0.64 0.43 0.94
DIABETES TYPE
Type 2 DM − − −
Secondary DM 1.50 1.34 1.68 1.39 1.24 1.55 1.23 1.15 1.31
Type 1 DM 1.11 1.05 1.18 1.06 1.00 1.13⁎ 1.08 1.02 1.15
DCSI LEVEL
0 − − −
1 1.33 1.18 1.49 1.23 1.10 1.38 1.11 0.99 1.24⁎
2 2.23 2.02 2.46 2.05 1.85 2.27 2.03 1.84 2.24
3 2.36 2.13 2.62 2.56 2.31 2.83 2.83 2.57 3.12
4 3.98 3.61 4.37 4.04 3.65 4.46 4.17 3.79 4.58
5 4.84 4.39 5.33 5.22 4.72 5.77 5.36 4.87 5.91
6 6.28 5.69 6.94 6.87 6.19 7.63 7.42 6.72 8.19
7 8.17 7.37 9.06 8.96 8.03 9.99 8.78 7.89 9.76
8 9.55 8.50 10.72 11.30 10.01 12.77 11.84 10.54 13.30
9 12.49 10.92 14.28 14.16 12.25 16.36 13.61 11.80 15.69
10+ 12.80 10.68 15.35 15.61 12.87 18.93 18.53 15.60 22.00

CL, confidence limit; DCSI, Diabetes Complications Severity Index.

⁎ Not statistically significant at an alpha level of 0.05.

Additionally, future refinements of the DCSI instrument might consider
the incorporation of depression and other behavioral health diagnoses,
codes for diabetes-related oral health, or more codes associated with
metabolic syndrome.
Any instrument like the DCSI that uses administrative data is only
as good as the accuracy of the claims submitted for reimbursement.
DCSI scores will most likely also be affected by incentives that can
drive intensive versus less intensive coding in fee-for-service versus
bundled or capitated payment models.
6. Conclusion
An enhanced DCSI system was developed to improve the clinical
accuracy of diabetes severity assignment and to allow incorporation of
ICD-10 codes. The usefulness of the proposed updated DCSI cannot be
fully assessed until the healthcare system has completed transition to
ICD-10. However, the new tool was designed with the coding
transition in mind and delivers reasonably credible results from
both a first principles and an outcomes perspective. Future work may
involve additional refinements to better-accommodate ICD-10 and
consider incorporating additional code categories. The LOINC code list
will also require periodic updates.
Acknowledgments
The authors wish to thank Vinay Chiguluri, MPH for providing
input based on his expertise with the DCSI tool, Tristan Cordier, MPH
for assistance with statistical methods, Lakshmi Kartha, MD for
creation of the code tables, and Teresa Rogstad, MPH for help with
quality checking and manuscript preparation.
Appendix A. Supplementary data
Supplementary data to this article can be found online at http://dx.
doi.org/10.1016/j.jdiacomp.2017.02.018.
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