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?
- Severe, morbid obesity
- Obesity
- BMI 40-40.5 and obesity
- 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?
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?
- Active
- History of
- Query
- 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.
- Recurrent MDD unspecified
- Recurrent MDD in full remission
- Recurrent MDD in partial remission
- History MDD
- Depressive mood
- Loss of interest or pleasure in most or all activities
- Insomnia or hypersomnia
- Change in appetite or weight
- Psychomotor retardation or agitation
- Lower energy
- Poor concentration
- Thoughts of worthlessness or guilt
- 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
Question 7: Please select the clinical indicator(s) used to query for dementia.
- Slums <20, failed mini-cog and MMSE
- Receiving: Namenda or Aricept
- Reported memory decline, increased confusion, difficulty completing tasks
- All the above
Explanation:
- Memory and mental health tests
- A neurological exam
- Blood tests
- Brain imaging tests
Dementia is an umbrella term describing diseases and conditions characterized by a chronic, global, and usually irreversible decline in memory, language, problem-solving, and other cognitive skills that affect a person’s ability to perform everyday activities.
The diagnosis is formed based upon the patient’s medical history, physical exam, and mental status exams. Two common mental status exams are the Mini-Mental State Examination (MMSE) and the Mini-Cog© Test. The Mini-Cog is a brief test that can identify the need for further evaluation. This test asks the individual to complete two tasks: repeating the names of three common objects a few minutes after they were introduced and drawing a simple clock face. The MMSE consists of questions designed to evaluate an individual’s mental skills. An individual’s score differentiates the severity of disease. It is expected that the score will decline 2–4 points as the disease progresses. Medications used in the treatment of dementia are designed to achieve two goals: slowing the progression and treating the symptoms. Aducanumab (Aduhelm™) is used to treat Alzheimer’s disease with the goal of reducing or delaying the cognitive and functional decline in the early stages.
There are several medications used to treat the symptoms of dementia, including donepezil (Aricept®), which is used to treat all stages of Alzheimer’s disease, and rivastigmine (Exelon®), which is used to treat mild to moderate Alzheimer’s dementia and dementia due to Parkinson’s disease. Galantamine (Razadyne®) is used to treat mild to moderate Alzheimer’s disease. Medications that work to improve memory, focus, and reasoning include memantine (Namenda®), memantine hydrochloride extended release, and donepezil hydrochloride (Namzeric®). Home health, social, and counseling services may also be ordered.
Question 8: A patient is noted to be receiving Farxiga. What medication indication should the CDI consider identifying when seeing Farxiga on the medication list?
- CHF
- CHF + Type 2 diabetes + CKD
- DM1 with CKD
- Option 1 and 2
Explanation:
Question 9: Patient’s vital signs: BP153/58, HR 60, BMI 36.26. Problem List: HTN, HLD, DM 2. What HCC opportunity is present?
- Severe obesity
- Obesity class 2 with comorbidity
- Obesity
- Both option 1 and 2
Explanation:
Question 10: A 79 year old patient presents for a follow-up visit for multiple conditions, including deep vein thrombus (DVT) of the lower extremity confirmed by US in 2023. The patient is currently asymptomatic. The patient was initially anticoagulated with Coumadin but switched to Xarelto. What is the presumed status of the DVT?
- Acute DVT
- Chronic DVT
- Recurrent DVT
- History of DVT, query provider
Explanation:
-
Based on the health record documentation, assign codes Z86.718, Personal history of other venous thrombosis and embolism, and Z79.01. Long term (current) use of anticoagulants, for history of recurrent deep vein thrombosis of the lower extremity on long term use of anticoagulant medication. In this case, the patient presented for a follow-up visit and had no evidence of an acute, current or recurrent DVT nor complications from the thrombus.
- Chronic DVT is a thrombus that is one month to several months old and usually involves symptoms, such as chronic swelling, ulceration, cellulitis, or other complications.
- Recurrent DVT indicates the condition has occurred more than once. The provider would need to document the recurrent or chronic DVT, to code it as such.
Question 11: A new diagnosis can be introduced in an AVW. Is this statement true or false?
- True
- False