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Monthly CDI Scenario Discussion – February 2021

Topic: Outpatient CDI: Diabetes with Chronic Complication

Office Visit 6/8/2020: 87-year old Caucasian female who lives with her son being evaluated today for diabetes. Her son reports elevated blood sugars in the past 4 weeks. Starting from yesterday the readings are 272, 172, 202, 242, and 198. These are on a daily basis in the morning. The patient herself denies any complaints. Appetite is good, she eats multiple snacks and consumes sweets. She is typically more active, but hasn’t been able to get out much and do her normal activities due to the COVID-19 pandemic.

PMH: HTN, HLP, DM2, GERD, Osteoporosis

Home medications: Prilosec 20mg capsule QD, Lipitor 20mg tablet QD, Fosamax 70mg takes q 7 days, Diovan 160mg QD, Levemir 20 units q HS

Vitals: BP-124/68, HR-84, Temp 98.2 degrees F (36.8 degrees C), Sp02 98%, Weight 91.8 kg (202 16 6.4 oz), Height 156.2cm (61.5”), BMI 37.6


  • Type 2 diabetes mellitus without complication, with long-term current use of insulin. Due for DM eye exam-will schedule. Son concerned about elevated blood sugars. Will increase Levemir to 30 units. Educated the son about the patient’s diet specifically to avoid sweets and try to exercise routinely. Return in 4 weeks for chronic medical conditions and her basic blood work including HbA1c. Son plans to check blood sugar twice a day and call us with the readings. Educated the patient to call us for blood sugars <100.
  • Essential hypertension. Goal blood pressure 140/90; currently on valsartan 160mg daily. Order Comprehensive Metabolic Panel: Future
  • Mixed Hyperlipidemia. Goal LDL <100; currently on atorvastatin 20mg daily. Order Fasting Labs: Future
  • GERD. Continue Prilosec
  • Osteoporosis. Continue Fosamax
  • BMI 37. Counseled on diet and exercise
  • Follow-up. Return in 4 weeks. Complete lab work prior to appointment
  • Lab work completed to be addressed on next appointment: HgbA1c 8.3 (6/10/2020)

Question: Are there query opportunities based on the scenario stated above?


  • Pt. has a known history of DM2 presenting on last office visit with c/o high sugars at home. Follow-up HbA1c noted to be 8.3
  • BMI 37.6 with a PMH of HTN, HLP, GERD and DM2. Pt. and son counseled on diet and exercise plan

Diagnostic criteria for Morbid Obesity: 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 two weight-related comorbid conditions.

UASI Recommends:

  • Query for Morbid Obesity
  • Query for DM with hyperglycemia

Documentation Without Clarification:


  1. Diabetes uncomplicated (HCC 19)
  2. HTN
  3. HLP
  4. GERD
  5. Osteoporosis


Demographic base factor: Community Enrollee-Non-dual Benefit, aged (Female 85-89): 0.641

HCC 19 risk factor: 0.105

Total: 0.746

Documentation With Clarification:


  1. Diabetes with hyperglycemia (HCC 18)
  2. HTN
  3. HLP
  4. GERD
  5. Osteoporosis
  6. Morbid Obesity (HCC 22)


Demographic base factor: Community Enrollee-Non-dual Benefit, aged (Female, 85-89): 0.641

HCC 18 risk factor: 0.302

HCC 22 risk factor: 0.250

Total: 1.193

CDI Educational Tips:

Include diabetic manifestations with highest level of specificity and current status.

 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. Providers completing their own coding may not be aware of these assumed relationships.

Poorly controlled, inadequately controlled, out of control, or uncontrolled diabetes must be clarified and documented as diabetes with hyperglycemia or hypoglycemia as appropriate.  

Educate office providers to include both the BMI and the associated medical diagnosis

Providers may be hesitant to document the term morbid obesity as patients can be sensitive to this diagnosis due to social stigma. With increased transparencies of chronic problems list seen through patient portals, providers may simply include the BMI instead of listing the associated medical diagnosis as well as assign only the z-code on office billing. Per Official Coding Guidelines BMI codes should only be assigned when there is an associated, reportable diagnosis (such as obesity). Therefore, this practice could lead to documentation of the BMI without a supportive diagnosis, resulting in noncompliant reporting.

Examples of weight-related comorbidities include but are not limited to diabetes, heart disease, stroke, HTN, arthritis, sleep apnea, gallbladder disease, or gout

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.