Clinical Documentation Improvement Example

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1. A 61-year-old white female who was transferred for a CABG. She had a recently placed left circumflex coronary artery stent, but was found to have significant LAD and left main disease. Select the proper CAD code.

a. 414.00

INCORRECT (correct answer is C): The appropriate code is 414.01, since the documentation does not state that this patient had a previous CABG procedure we have to assign the code understanding that this current procedure will be performed on the patient’s native coronary arteries.

b. 414.02

c. 414.01

CORRECT: The appropriate code is 414.01, since the documentation does not state that this patient had a previous CABG procedure we have to assign the code understanding that this current procedure will be performed on the patient’s native coronary arteries.

d. 414.2

2. 50-year-old diabetic patient presents with dizziness and headaches. He is having trouble getting his sugar down. It is up to 200. Sometimes he takes as much as Humalog 50/50 80 units at a time. Based on the documentation what type of diabetes does he have?

a. IDDM

INCORRECT (correct answer is B): This patient could have either type I or type II DM. However, the documentation above does not support reporting as a type I diabetic. Simply because he is on insulin does not make him a type I diabetic. The correct answer is B) Type II. In order to appropriately report the type I code, 250.01, the clinician must specifically state that the patient has type I DM. The old standard of thought that if a patient uses insulin then they must have Type I diabetes is incorrect. Many patients with Type II diabetes who cannot be controlled with diet, exercise, and oral medications are treated ultimately with insulin. As coder’s we understand that clinicians have certain preferred terms that they choose to use interchangeably. It is important to maintain an understanding of all new terms as well as the clinicians' preferences.

b. Type II

CORRECT: This patient could have either type I or type II DM. However, the documentation above does not support reporting as a type I diabetic. Simply because he is on insulin does not make him a type I diabetic. The correct answer is B) Type II. In order to appropriately report the type I code, 250.01, the clinician must specifically state that the patient has type I DM. The old standard of thought that if a patient uses insulin then they must have Type I diabetes is incorrect. Many patients with Type II diabetes who cannot be controlled with diet, exercise, and oral medications are treated ultimately with insulin. As coder’s we understand that clinicians have certain preferred terms that they choose to use interchangeably. It is important to maintain an understanding of all new terms as well as the clinicians' preferences.

c. Type I

d. insulin dependent diabetic

3. Glucose intolerance is:

a. A hereditary disease of obese individuals

INCORRECT (correct answer is C): Glucose intolerance is the inability of the body to lower serum glucose levels. It is a type of digestive disorder which occurs when the body fails to digest sugars found in foods such as carbohydrates and sweets. Over time, this can develop into insulin resistance, which occurs when the body's normal response to insulin being released or injected is reduced. Both conditions come into play when it comes to stabilizing the body and minimizing blood glucose levels. From a coder’s perspective, it is important to know that if a patient is diagnosed as being glucose intolerant that you assign the code for glucose intolerance (271.3) rather than automatically assigning the diabetes mellitus code. The documentation must specifically state the diagnosis of diabetes in order to report it appropriately.

b. Severe nausea and vomiting after eating junk food

c. Inability to lower serum glucose levels

CORRECT: Glucose intolerance is the inability of the body to lower serum glucose levels. It is a type of digestive disorder which occurs when the body fails to digest sugars found in foods such as carbohydrates and sweets. Over time, this can develop into insulin resistance, which occurs when the body's normal response to insulin being released or injected is reduced. Both conditions come into play when it comes to stabilizing the body and minimizing blood glucose levels. From a coder’s perspective, it is important to know that if a patient is diagnosed as being glucose intolerant that you assign the code for glucose intolerance (271.3) rather than automatically assigning the diabetes mellitus code. The documentation must specifically state the diagnosis of diabetes in order to report it appropriately.

d. Characteristic of Type 1 diabetes only

e. Synonymous with hypoglycemia

4. Metabolic syndrome refers to all of the following except:

a. Dysmetabolic syndrome

INCORRECT (correct answer is D): Metabolic syndrome is a name for a group of risk factors that occur together and increase the risk for coronary artery disease, stroke, and type 2 diabetes. This syndrome can also be called dysmetabolic syndrome, syndrome X, or insulin resistance. Hypermetabolism is a condition characterized by an abnormal increase in the body’s basal metabolic rate. It usually occurs when there is significant injury or multiple traumas to the body. It is important to understand from a coder’s view that one disease or syndrome can be referred to in documentation in several different ways. To have an understanding of this can save you time in looking up information.

b. Syndrome X

c. Insulin resistance

d. Hypermetabolism

CORRECT: Metabolic syndrome is a name for a group of risk factors that occur together and increase the risk for coronary artery disease, stroke, and type 2 diabetes. This syndrome can also be called dysmetabolic syndrome, syndrome X, or insulin resistance. Hypermetabolism is a condition characterized by an abnormal increase in the body’s basal metabolic rate. It usually occurs when there is significant injury or multiple traumas to the body. It is important to understand from a coder’s view that one disease or syndrome can be referred to in documentation in several different ways. To have an understanding of this can save you time in looking up information.

e. None of the above

5. Renin is:

a. Released from the kidneys, helps maintain ECF volume

CORRECT: Renin is a protein (enzyme) released by special kidney cells to help maintain ECF volume when you have decreased salt (sodium levels) or low blood volume.

b. A popular pop/rock performer

INCORRECT (correct answer is A): Renin is a protein (enzyme) released by special kidney cells to help maintain ECF volume when you have decreased salt (sodium levels) or low blood volume.

c. Not involved in release of aldosterone

INCORRECT (correct answer is A): Renin is a protein (enzyme) released by special kidney cells to help maintain ECF volume when you have decreased salt (sodium levels) or low blood volume.

d. Secreted from the adrenal cortex

INCORRECT (correct answer is A): Renin is a protein (enzyme) released by special kidney cells to help maintain ECF volume when you have decreased salt (sodium levels) or low blood volume.

e. Primarily pulmonary hypertension prevention

INCORRECT (correct answer is A): Renin is a protein (enzyme) released by special kidney cells to help maintain ECF volume when you have decreased salt (sodium levels) or low blood volume.

6. Local vascular beds are:

a. Made up of the aorta and vena cava

INCORRECT (correct answer is C): Blood vessels readily adapt their design in response to sustained functional changes. This is called local vascular beds. Marked rises in pressure may result from these changes and can be a major causative element in primary hypertension.

b. Not affected by nitric acid

c. Able to regulate blood flow as needed by a particular organ

CORRECT: Blood vessels readily adapt their design in response to sustained functional changes. This is called local vascular beds. Marked rises in pressure may result from these changes and can be a major causative element in primary hypertension.

d. Not lined with endothelium

e. Known to have flow regulated by the thyroid gland

7. A study to evaluate the electrical activity of the heart is all of the below except:

a. ECG

INCORRECT (correct answer is C): Of the options given, EEG is not a study performed to evaluate the electrical activity of the heart. An Electroencephalography (EEG) is the recording of electrical activity along the scalp. EEG measures voltage fluctuations resulting from ionic current flows within the neurons of the brain. Since each of these studies has a separate CPT® code, it is important to understand the purpose of the different tests performed for various diseases. Having this knowledge will increase your coding productivity and decrease the amount of time spent researching.

b. EKG

c. EEG

CORRECT: Of the options given, EEG is not a study performed to evaluate the electrical activity of the heart. An Electroencephalography (EEG) is the recording of electrical activity along the scalp. EEG measures voltage fluctuations resulting from ionic current flows within the neurons of the brain. Since each of these studies has a separate CPT® code, it is important to understand the purpose of the different tests performed for various diseases. Having this knowledge will increase your coding productivity and decrease the amount of time spent researching.

d. Electrocardiogram

e. None of the above

8. All of the following are coronary arteries except:

a. LCA

INCORRECT (correct answer is B): LAX is an airport in Los Angeles, California. With the amount of alphabet soup in the medical field, it is important to remain up-to-date on currently approved and recognized medical abbreviations.

b. LAX

CORRECT: LAX is an airport in Los Angeles, California. With the amount of alphabet soup in the medical field, it is important to remain up-to-date on currently approved and recognized medical abbreviations.

c. LAD

d. RCA

e. None of the above