{"id":16220,"date":"2026-10-21T06:36:00","date_gmt":"2026-10-21T06:36:00","guid":{"rendered":"https:\/\/medical-article.com\/?p=16220"},"modified":"2026-10-21T06:36:00","modified_gmt":"2026-10-21T06:36:00","slug":"medicine-gave-itself-a-code-for-diabetes-remission-a-year-later-the-payment-system-still-cant-see-it","status":"publish","type":"post","link":"https:\/\/medical-article.com\/?p=16220","title":{"rendered":"Medicine Gave Itself a Code for Diabetes Remission. A Year Later, the Payment System Still Can\u2019t See It."},"content":{"rendered":"
\n<\/div>\n

By HANA KAHLEOVA<\/p>\n

\u201cWill this only get worse?\u201d<\/p>\n

Patients with type 2 diabetes have asked me some version of that question for my entire career. For most of it, the honest answer was \u201cprobably.\u201d We treated diabetes as a one-way street: glucose climbs, medications pile up, complications follow. Good care slowed the slope. It didn\u2019t reverse it.<\/p>\n

A year ago today, that assumption stopped being true, at least on paper. On October 1, 2025, CMS added E11.A, \u201ctype 2 diabetes mellitus in remission,\u201d<\/a> to the ICD-10-CM code set. To use it, a clinician has to document an HbA1c below 6.5% for at least three months after a patient has stopped all glucose-lowering medication. That\u2019s the definition the American Diabetes Association, the Endocrine Society, the European Association for the Study of Diabetes, and Diabetes UK agreed on in 2021<\/a>. \u201cWell controlled\u201d doesn\u2019t count. The code exists to separate remission from management.<\/p>\n

That\u2019s a real concession. When CMS creates a code for an outcome, it is saying the outcome is real, measurable, and common enough to track.<\/p>\n

The evidence behind it isn\u2019t new. In DiRECT<\/a>, a cluster-randomized trial run through ordinary UK primary care practices, 46% of participants in a structured weight-management program were in remission after a year, compared with 4% on usual care. About a third were still in remission at two years<\/a>. These weren\u2019t patients at an elite research center. They came from routine general practices. That\u2019s what makes the result a policy question, not a curiosity.<\/p>\n

So here\u2019s the policy question. One year in, what has the code changed?<\/p>\n

As far as payment and quality measurement go, almost nothing.<\/p>\n

<\/span><\/p>\n

A code with nowhere to go<\/strong><\/p>\n

E11.A gives clinicians a precise way to document remission. It does nothing to reward pursuing it, measure it, or pay for the care that produces it. Three systems decide what actually happens in a clinic and a health system\u2019s budget. None has caught up.<\/p>\n

Payment<\/em>.<\/strong> DiRECT was intensive: several months of total diet replacement, then structured food reintroduction and regular follow-up for two years. Compare that with what Medicare covers. Medical nutrition therapy for diabetes is capped at three hours in the first year and two hours a year after that<\/a>. Medicare\u2019s one structured lifestyle program, the Diabetes Prevention Program, is open only to people who don\u2019t have diabetes yet. Once you\u2019re diagnosed, the benefit built for behavior change is gone.<\/p>\n

Meanwhile, the money is flowing somewhere else. GLP-1 drugs are effective and the right choice for many patients, and the global market for this class is projected to reach roughly $100 billion a year by 2030<\/a>. That isn\u2019t an argument against the drugs. It\u2019s a map of where the system is willing to spend, and where it isn\u2019t.<\/p>\n

Quality measurement. <\/em>HEDIS, Medicare Advantage Star Ratings, and MIPS reward hitting glycemic and blood pressure targets. None of them give a plan or practice credit for a patient who no longer meets the definition of diabetes. That patient just drops out of the denominator.<\/p>\n

And the bar keeps moving the other way. Last month, CMS released draft cutpoints for the 2027 Star Ratings<\/a>, and roughly half became harder to hit than in 2026. The kidney health evaluation measure for patients with diabetes tightened by 7 to 10 points, depending on the star level. Plans are being pushed to manage diabetes more precisely than ever, on a scorecard with no line for the best outcome a patient can have.<\/p>\n

Incentives<\/em>.<\/strong> Put those two together and the business case writes itself, in the wrong direction. A health system that invests in getting patients into remission pays for an intensive program out of pocket and gets nothing on its quality scores for the result. A system that manages the disease indefinitely gets paid for every visit and every refill, and scored on every target.<\/p>\n

Picture a patient two years past diagnosis, on two medications, with an HbA1c of 7.2%. If her health system enrolls her in an intensive program and she reaches remission, it has spent money it won\u2019t recover, and its diabetes measures look exactly as they would if she had moved away. If it adds a third medication instead, it gets paid, and she counts toward the target. Every incentive points to the prescription.<\/p>\n

The infrastructure already exists<\/strong><\/p>\n

E11.A was created to solve a documentation problem, so coders would stop guessing when a physician wrote \u201cremission\u201d in a chart. But a system that can identify remission that precisely can also reward it. Nothing downstream uses it yet.<\/p>\n

Three changes would close the gap. None requires new clinical evidence.<\/p>\n

First, build E11.A into quality measurement.<\/em> <\/em><\/strong>NCQA and CMS could add a remission measure to HEDIS, Star Ratings, and MIPS using the code and the 2021 consensus definition. A health system that helps a patient leave the diabetic population should get credit for it, not just lose that patient from the denominator.<\/p>\n

Second, create a payment pathway for remission programs.<\/em> Cover time-limited, structured weight-management and dietary programs modeled on DiRECT for patients in the first several years after diagnosis, when remission is most achievable. Pay for engagement and glycemic outcomes, not visit counts. CMS\u2019s Innovation Center is the natural place to test it.<\/p>\n

Third, fund the maintenance phase.<\/em> Relapse is common without follow-up. The lower-intensity support over several years that separates durable remission from a temporary dip in HbA1c is the least-funded part of the whole pathway, and it\u2019s where programs fail.<\/p>\n

Who this is for, and who it isn\u2019t<\/strong><\/p>\n

Remission isn\u2019t realistic for everyone with type 2 diabetes, especially later in the disease, after substantial loss of insulin-producing capacity. For many patients, long-term medication remains the right, evidence-based goal.<\/p>\n

The argument is narrower. For patients who could realistically get there, whether anyone offers them the chance shouldn\u2019t depend on whether their health system\u2019s scorecard happens to notice an outcome CMS created a code to describe.<\/p>\n

More than 38 million Americans have diabetes<\/a>, the vast majority of them type 2. CMS has done the hard part: it built a precise, clinically rigorous way to say a patient\u2019s diabetes is gone. With final 2027 Star Ratings expected this month, now is the time to ask why the scorecard still can\u2019t see it.<\/p>\n

Hana Kahleova, MD, PhD, is a physician board-certified in internal medicine, endocrinology, and lifestyle medicine, and director of clinical research at the Physicians Committee for Responsible Medicine<\/a>, a nonprofit that advocates plant-based nutrition. PCRM had no role in the DiRECT trial or in the CMS policies discussed here.<\/em><\/p>","protected":false},"excerpt":{"rendered":"

By HANA KAHLEOVA \u201cWill this only get worse?\u201d Patients with type 2 diabetes have asked me some version of that question for my entire career. For most of it, the honest answer was \u201cprobably.\u201d We treated diabetes as a one-way street: glucose climbs, medications pile up, complications follow. Good care slowed the slope. It didn\u2019t…<\/p>\n","protected":false},"author":0,"featured_media":16219,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[2],"tags":[],"class_list":["post-16220","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-articles"],"_links":{"self":[{"href":"https:\/\/medical-article.com\/index.php?rest_route=\/wp\/v2\/posts\/16220"}],"collection":[{"href":"https:\/\/medical-article.com\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/medical-article.com\/index.php?rest_route=\/wp\/v2\/types\/post"}],"replies":[{"embeddable":true,"href":"https:\/\/medical-article.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=16220"}],"version-history":[{"count":0,"href":"https:\/\/medical-article.com\/index.php?rest_route=\/wp\/v2\/posts\/16220\/revisions"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/medical-article.com\/index.php?rest_route=\/wp\/v2\/media\/16219"}],"wp:attachment":[{"href":"https:\/\/medical-article.com\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=16220"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/medical-article.com\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=16220"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/medical-article.com\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=16220"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}