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Monthly CDI Scenario Discussion – October 2023

Topic Outpatient CDI: Pacemaker Status, Sacroiliitis

Office Visit: 76-year-old female, lives alone.  Follow up re: Cardiology, Orthopedic (low back pain) follow up, refills needed.

PMH: Hypothyroidism, CAD, Osteoarthritis, Lung Cancer, Pacemaker status, lawn mower accident as teenager- amputation of fourth, fifth toe on left foot.

Home medications:   Oscal, Synthroid, Losartan

Vitals: BP 115/64, HR 98, Temp 98.4, SpO2 96%, Weight 102 kgs., Height 187 cm, BMI 29.3


Arthritis/Sacroiliac pain: follows with outside Orthopedics, Longstanding problems with low back pain, primarily sacroiliac pain, last set of x rays ( 5-23-23) did show significant arthritis in her low back  as well as her sacroiliac joints noted widening, bilateral erosion of SI joints, does complete some low back stretches in the morning, pain primarily when standing for long period of time, previously tried chiropractic care, injections into joints in 2022, did not feel it helped, will need physical therapy and follow up with Ortho.

CAD: Refused cholesterol medications, attempting to follow low fat diet. Pacemaker in place. Importance of following up with Cardiology discussed. Last Pacer check report on record -pacemaker dependent, history of heart block.

Hypothyroidism: Labs reviewed, refill script, no changes.

Lung Cancer: treated in 2000 with radiation, quit smoking in 1980’s. No current symptoms. Surveillance CT in 2022 negative. Oncology appointment   last month, per patient “all good.” Follow up in 1 year or sooner if needed.

Pacemaker: Post-surgery 2022, follows with Cardiology, syncope with severe heart sinus rhythm issues.

Follow-up: Return in 4 to 6 months, follow up with Orthopedics, start Physical Therapy-orders sent, Cardiology next month.

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

Discussion: Provider visit diagnoses include Arthritis, CAD, Hypothyroidism, Pacemaker status, Lung Cancer

UASI Recommends:

Query for specificity of Arthritis

Query for type of arrhythmia for underlying “heart sinus issues”

Query for current status of Lung Cancer

CDI Education Tips

Review medical record for any consulting physician notes. Often electronic notes can also be found from outside specialists that provide additional assessments, diagnoses, and treatment modalities.  Use supportive clinical information, radiology findings, treatment plans, medications, and/or physical assessments to query provider for specificity of arthritis. Specific radiology findings such as erosion, sclerosis, widening, narrowing, and /or partial joint fusions are possible indicators of an underlying specific type of arthritis.

Coding Clinic, first Quarter 2019 states that it is appropriate to code both the presence of sick sinus syndrome and the presence of a cardiac device. The pacemaker controls the heart rate, it does not cure the SSS and the condition is still being managed and monitored.

Recent Office of Inspector General (OIG) audit findings included incorrectly submitted diagnoses codes for colon, renal, lung, and breast cancer where medical records indicated the individual patient had previously had cancer, but their records did not justify a cancer diagnosis at the time of the physician’s service.  For example, documentation noted the cancer was treated over twenty years prior with no evidence of disease currently.

‘History of’ can be a vague term and have different meanings. Educate providers to discuss condition(s) in current state and that diagnoses that have resolved or are no longer treated should not be reported. Query the provider when the documentation is unclear or inconsistent. When working with Providers encourage them to update the patient problem list: resolving or revising to historical conditions.

Z codes are often overlooked by providers in the office setting. TOAD is an abbreviation that helps providers quickly remember:

Transplants, Ostomies, Amputations/AIDS, Dialysis Status

  •  HCC Updates for 2024: Version 28 increases HCCs by 268 new ICD-10-CM codes
  •  V28 will increase the number of payment HCCs by 29 for a total of 115 payment HCCs. These 115 HCCs have been renumbered and renamed.
  • Significant diagnoses to be added: • Anorexia nervosa, bulimia nervosa • Alcoholic hepatitis with and without ascites • Malignant pleural effusion • Obstruction of bile duct • Severe, persistent asthma • Toxic liver disease with hepatitis

Disclaimer: 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.