Office Visit 11/12/2021:78-year-old gentleman, lives with wife. Recently hospitalized from11-6-2021 to 11-10-2021
PMH: Diabetes type 2, Obesity, History of Falling
Home Medications: Metformin 500mg BID, Gabapentin 300mg BID
Vitals: BP 115/64, HR 98, Temp 98.4, SpO2 96%, Weight 168 lbs., Height 5ft., BMI 32.8
Assessment/Plan:
- Stroke: Continues OP physical therapy, weakness remains post CVA on right hand, arm, right leg- having difficulty with silverware, writing as patient is right handed. Good mood.
- Diabetes: On controlled diet, A1c at 6.4, checking sugars at home infrequently, describes feet numbness and tingling bilaterally, monofilament testing 4 of 10, will add Gabapentin
- Obesity: Counseled on diet
- General Health Instructions: Wear mask in large groups, practice good handwashing, call for any questions
- Follow-up: Return in 1 month
Question: Are there query opportunities based on the scenario stated above?
Discussion: Provider visit diagnoses include Stroke. Hospitalization 11-6-2021 thru 11-10-2021.Patient undergoing physical therapy post stroke as OP. Provider A/P includes description of numbness/tingling to the patient’s feet. Patient on Gabapentin, which can be used to treat neuropathic pain.
UASI Recommends:
- Query for diagnosis to support use of Gabapentin.
- Query for any existing co-condition of Diabetes.
- Use Hemiparesis, post CVA affecting right dominant side.
Documentation with and without clarification:
| Documentation without clarification | Documentation with clarification |
| Diagnoses: Stroke (HCC 100) Diabetes type 2 (HCC 19) Obesity Factor Demographic base factor: Community Enrollee-Non-dual Benefit, aged (Male 75-79): 0.451 HCC 86 risk factor 0.23 HCC 111 risk factor 0.105 | Diagnoses: Hemiparesis, post CVA affecting right dominant side (HCC 103) Diabetes type 2 with diabetic peripheral neuropathy (HCC 18) Obesity Factor Demographic base factor: Community Enrollee-Non-dual Benefit, aged (Male 75-79): 0.451 HCC 103 risk factor .437 HCC 18 risk factor 0.302 |
| Total: 0.786 | Total: 1.19 |
CDI Educational Tips:
Recent Office of Inspector General (OIG) reports Acute Stroke was an identified diagnosis that was at higher risk for being miscoded on outpatient visit claims.
Stroke would rarely be appropriate to code in the office setting. Even if suspected, OP Coding guidelines state any term indicating an uncertain or inconclusive diagnosis is not assigned an ICD-10-CM code.
Complete review of chart to include any post stroke related deficits that might be present and able to capture if appropriate or revise diagnosis of stroke to personal history of (which does not map to an HCC).
Educate providers on stroke related conditions including ataxia, dysphagia, weakness, and speech /language impairment.
Remember hemiparesis is weakness on half of the body. Coding Clinic, First Quarter 2015, states that, “unilateral weakness that is clearly documented as being associated with a stroke, is considered synonymous with hemiparesis or hemiplegia. Unilateral weakness outside of this clear association can not be assumed as hemiparesis/hemiplegia, unless it is associated with some other brain disorder or injury.”
When working with Providers encourage them to update the patient problem list: resolving or revising acute conditions.
Patients with diabetes often develop conditions that affect various body systems due to the diabetes and these conditions are considered complications. If a complication is listed in the ICD-10 Alphabetic Index as Diabetes ‘with’, then the condition is assumed to be due to the diabetes and is reported as a diabetic complication, unless the provider clearly states the condition is unrelated to diabetes (or another guideline exists that specifically requires provider documentation to link the two conditions). For example, sepsis guidelines require that provider documentation clearly link organ failure to sepsis.
This is a short synopsis of a possible patient record and is not intended to be all inclusive. This is for educational purposes only and not intended to replace your institutional guidelines.