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

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:

Dementia is a broad term for conditions that can impair someone’s ability to remember, process information, and speak. Early indicators can include issues with short-term memory and word finding.
A doctor or healthcare professional will likely refer the person to a neurologist who can determine whether the symptoms are related to dementia or another issue. A neurologist may order:
  • Memory and mental health tests
  • A neurological exam
  • Blood tests
  • Brain imaging tests
With treatment and early diagnosis, you may be able to slow down the progression of dementia and maintain mental function for a longer period of time. The treatments may include medications or cognitive training.
https://www.healthline.com/   

 

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.

https://pro.acdis.org/user/login?destination= 

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: 

Farxiga lowers the risk of going to hospital for heart failure in adults with type 2 diabetes who also have cardiovascular disease or multiple risk factors for cardiovascular disease; lowers the risk of further worsening of kidney disease, end-stage kidney disease (ESKD), death due to cardiovascular disease, and hospitalization for heart failure in adults with chronic kidney disease at risk of progression.
AstraZeneca’s FARXIGA (dapagliflozin) has been approved in the US to reduce the risk of cardiovascular (CV) death, hospitalization for heart failure (hHF), and urgent heart failure (HF) visits in adults with HF. The approval by the Food and Drug Administration (FDA) was based on positive results from the DELIVER Phase III trial 1. FARXIGA was previously approved in the US for adults with HF with reduced ejection fraction (HFrEF). /www.astrazeneca-us.com 

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: 

Most recent BMI >= 35 and at least one weight related comorbid condition. For example: diabetes, HTN, heart disease, history of stroke, obstructive sleep apnea, hyperlipidemia, etc.
E66.01 maps to morbid, severe obesity, or severe obesity with comorbid conditions. Morbid obesity: Obesity that significantly increases the risk of one or more obesity-related health conditions or serious diseases (also known as comorbidities). The National Institute of Health defines obesity as morbid if the patient demonstrates a BMI of over 40, or a BMI of 35 or more and at least one weight-related comorbid condition, such as diabetes, heart disease, stroke, hypertension, and arthritis.
https://pro.acdis.org/outpatient/conditions/morbid-obesity-0

 

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.
AHA Coding Clinic, Second Quarter 2020, p. 20: Assign Z86.718, Personal history of other venous thrombosis and embolism, for documentation of “recurrent deep vein thrombosis of the lower extremity.”

Question 11: A new diagnosis can be introduced in an AVW. Is this statement true or false?

  • True
  • False
Explanation:
A significant, separately identifiable, medically necessary evaluation and management (E/M) service is required for the additional service addressing the new diagnosis. An additional CPT code (99202–99205, 99211–99215) with modifier 25 is required and may incur a charge to the patient.
MLN6775421 – Medicare Wellness Visits
Guidelines for Achieving a Compliant Query Practice—2022 Update
December 14, 2022 Position Papers, ACDIS Guidance, Physician Queries
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