Outpatient Clinical Documentation Integrity (OP CDI) is always evolving. Let’s test your knowledge.  On our LinkedIn page, we will have a series of questions so you can test your knowledge about OP CDI.

Play along on Harmony Healthcare’s LinkedIn page and then come back here to check your answers.

Question 1: A patient with HTN, HLD, CHF, and a history of CVA noted to have a BMI of 40.71 on the previous DOS last month. What is the HCC opportunity?

  1. Severe, morbid obesity
  2. Obesity
  3. BMI 40-40.5 and obesity
  4. Option 1 and 3

Explanation:

  • From Coding Clinic 2nd quarter, pg 9. Class 3 obesity: Assign code E66.01, Morbid (severe) obesity due to excess calories, for Class 3 obesity. Class 3 obesity is synonymous with morbid obesity, which is classified to code E66.01.
  • BMI must include a nutritional status diagnosis that addresses a form of malnutrition, overweight, obesity, or morbid obesity that is documented by an acceptable provider. (Per AHA Coding Clinic 4th quarter 2018)
  • Clinical support: Morbid Obesity: most recent BMI >= 40 or most recent BMI >= 35 and at least one weight related cormorbid condition, for example: Diabetes, HTN, heart disease, stroke, arthritis and obstructive sleep apnea, GERD, hyperlipidemia, gallbladder disease, hyperuricemia and gout

 

Question 2: There is external documentation from oncology that noted DCIS of right breast confirmed by biopsy. An upcoming visit is to discuss a plan of treatment. This diagnosis is not on any internal documentation or claim. Is this query opportunity for an HCC capture in the facility?

1.           Yes
2.           No
Explanation:  D05.11 is a billable diagnosis code used to specify a medical diagnosis of intraductal carcinoma in place of right breast and is not an HCC in Version 24 or Version 28.

Question 3: Here is an encounter note: Blood pressure elevated at 153/58 which we continue to monitor. Counseled on reducing carbs and sweets and to increase activity such as walking daily. Continues to smoke. Started Wellbutrin for smoking cessation. Blood sugars are stable with a recent A1C of 6.6%. Followed by Oncology for breast cancer. Medication List: Crestor, Lisinopril, ASA, Anastrozole, metoprolol, Omega 3, Wellbutrin, Eliquis, Metformin and Sertraline. Provider documented active breast cancer, status post mastectomy, followed by oncology. What is the status of the breast cancer?

  1. Active
  2. History of
  3. Query
Explanation:
  • The patient is still receiving treatment (Anastrozole).
  • Treatment of breast cancer: Mastectomy, lumpectomy, chemotherapy, XRT, estrogen therapy for ER positive breast cancer (such as Letrozole, Tamoxifen, Anastrozole, Exemestane).
    AAPC Healthcare monthly 11/1/17

Question 4: What CMS HCC model captures dialysis in the renal hierarchy?

  • V24
  • V28
  • Both V24 and V28
  • None of the above

Explanation: Z99.2, dialysis status maps to HCC 134 in Version 24. It is not a separate HCC in Version 28.

Question 5: What would be the correct recurrent MDD choice if PHQ 9 = 0 for 3 consecutive months, asymptomatic and receiving Wellbutrin? Please select the most relevant diagnosis for MDD.

  1. Recurrent MDD unspecified
  2. Recurrent MDD in full remission
  3. Recurrent MDD in partial remission
  4. History MDD
Explanation:
AAPC 2013: For a classification of in remission the patient has had two or more depressive episodes in the past but has been free from depressive symptoms for several months. This category can still be used if the patient is receiving treatment to reduce the risk of further episodes. It will be based on the provider’s clinical determination and documentation.
According to the American Psychiatric Association, patients must exhibit five or more of the nine symptoms for at least two weeks to qualify for an initial diagnosis of MDD – One symptom must either be (1) Depressed mood or (2) Loss of interest or pleasure.
Full list of symptoms:
  1. Depressive mood
  2. Loss of interest or pleasure in most or all activities
  3. Insomnia or hypersomnia
  4. Change in appetite or weight
  5. Psychomotor retardation or agitation
  6. Lower energy
  7. Poor concentration
  8. Thoughts of worthlessness or guilt
  9. Recurrent thoughts of death or suicidal ideation

Question 6: You can ask a “yes/no” query when introducing a new diagnosis.

  • True
  • False

Explanation: 

  • Yes/no: Yes/no queries should only be employed to clarify documented diagnoses that need further specification. Yes/no queries may not be used in circumstances where only clinical indicators of a condition are present.
  • Multiple choice: Multiple choice query formats should include clinically significant and reasonable option(s) as supported by clinical indicator(s) in the health record, recognizing that occasionally there may be only one reasonable option. Providing a new diagnosis as an option in a multiple choice list—as supported and substantiated by referenced clinical indicator(s) from the health record—is not introducing new information. There is no mandatory or minimum number of choices necessary to constitute a compliant multiple-choice query.

ACDIS/AHIMA: Guidelines for Achieving a Compliant Query Practice—2022 Update 12/14/22

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