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: 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
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