Huddle Up
This is an example of an appointment type where using the daily huddle is not recommended.
What is n/a - there is critically important information present on patients for most encounters, including information on healthcare utilization, suspected diagnoses or conditions, and medication adherence cues.
80 year old male patient with long-standing diabetes and Stage 4 CKD (secondary to the diabetes) is seen in the clinic. This is the number of codes needed to accurately and completely describe his diabetes, and this is what the code(s) is.
What is 2 ICD-10 codes
E11.22 - Type 2 diabetes mellitus with diabetic chronic kidney disease
N18.4 - Chronic kidney disease, stage 4 (severe)
Diabetes coding is hard and complicated - lots of different conditions can be complications of diabetes. Codes E11.8 and E11.69 seem to encompas and describe everything well enough, and is an easy button. Name a concern with this logic
E11.8: DM with unspecified complications
E11.69: DM with other specified complications
Complications in the coding sense refer to a secondary disease or clinical manifestation that has been cause by the diabetes.
A second code is needed when billing either E11.69 to describe what the complication is, and is only appropriate when there isn't an appropriate code that already describes the complication of the patient's.
The patient's breast cancer was removed and successfully treated with a lumpectomy last year. Currently the patient is undergoing active surveillance, this is the most active ICD-10 code based on the current available information.
What is: Z85.3: Personal history of malignant neoplasm of breast
You see a patient for Diabetes that is complicated by Retinopathy, Neuropathy, and Chronic Kidney Disease - Stage IIIb. All of these diagnoses route to the same Diabetes HCC - Diabetes with Chronic Complications. Do I really need to bill all of them? Why?
Each of these diagnoses communicate additional information, past that their diabetes has chronic complications.
Which of the following is not a source for potential / suspected conditions found on the daily huddle
Pharmacy Data (Suspect condition of Depression based on a filled prescription for Venlafaxine)
Previously Billed ICD-10 or HCC codes: Conditions billed previous years but not billed this year
Staged (Worsened) Condition Codes - ie: the patient had Stage IIIb CKD last year, therefore stage IV is suggested this year
Integrated Data from Clinical Data feeds (BMI, A1cs)
Sneaky Care Gap Question.....
True or False: CGM data can be used to close the Glycemic Status assessment in patients with Diabetes
True - starting in 2024 the GSD quality metric can be closed with either Hemoglobin A1c or CGM data.
A 64 year old patient comes in today for follow up. She has hypertension and diastolic heart failure. She is feeling well on her current medication regimen and there is no signs of hear failure exacerbation. Her blood pressure is currently at goal and her weight is stable. Which if any of the diagnoses currently best describe the patient:
I50.32 - Chronic diastolic (congestive) heart failure
I11.0 - Hypertensive heart disease with heart failure
I10 - Essential (primary) hypertension
I50.32 - Chronic diastolic (congestive) heart failure
and
I11.0 - Hypertensive heart disease with heart failure
What is the only clinical situation when I63 - Acute Ischemic Stroke should be coded in the outpatient, clinical setting?
What is when a patient is seen in the clinic and is actively having an acute ischemic stroke?
In patients with dementia, they usually require this many ICD-10 diagnoses codes to accurately and completely describe the patient and their dementia's medical complexity.
Two codes are typically required to fully report dementia: 1st to code the underlying condition, 2nd to code dementia severity and/or behavioral disturbances.
1. Code first the underlying physiological condition or sequelae of cerebrovascular disease
2. Code second dementia severity and behavioral disturbances.
True or false: In our office the medical assistant prints the daily huddle for all patients scheduled just prior to their arrival, then the MA hands the huddle to the clinician before they go in to see the patient. These are options that care teams can take to follow up on huddle suspected conditions were addressed (resolved by being placed on a claim or dismissing a potential diagnosis).
What is developing a system to review huddles after the visit to dismiss erroneous suspected conditions?
What is coding team to review huddle sheets at the time of billing?
58 year old diabetic patient with difficulty with medication adherence whose A1C last week was 8.5%. He is up to date on all diabetic screenings and does not have retinopathy, neuropathy or nephropathy. Review of his glucometer readings show frequent readings above 400mg/dL. Based on the current clinical information this would be the correct code.
What is E11.65 - Type 2 diabetes mellitus with hyperglycemia?
A 66 year old patient comes in today for follow up. His blood pressure is well-controlled on lisinopril and his asthma is well-controlled with fluticasone/salmeterol twice a day. He uses his albuterol less than once a month and never at night. He has had moderate persistent asthma for many years. Based on the documentation, these are the appropriate diagnoses to code.
What is Moderate Persistent Asthma, without exacerabation: J45.40
and Essential Hypertension I10
Following an acute heart attack, this is the length of time that the I21 - Acute Myocardial Infarction code can be billed, prior to changing the code to I25 - Old / Previous Myocardial Infarction
What is 4 weeks?
A patient has a coding suggestion of morbid obesity based on having E66.01 (Morbid Obesity) and Z68.42 (BMI-45) billed at her AWV last year. Since last year, they have lost significant weight decreasing their BMI to 35, but has developed hypertension. This is the correct diagnoses for the patient's weight related medical problems
E66.01 - Morbid Obesity
Z68.35 - BMI: 35
These are the ways a clinic can "get credit" for addressing / resolving suspected potential diagnoses
What are by Documenting - and putting a diagnosis on the claim and Dismissing a suspected condition/diagnosis. Equal credit is given for dismissing as well as documenting and billing a suspected diagnosis.
80 year old patient comes in for a preoperative risk assessment prior to undergoing a planned fem-pop bypass for peripheral artery disease due to many years of poorly controlled diabetes. His current A1C is 7.5% from last week. Which of the following codes would best (currently) describe his diabetes?
E11.8 - Type 2 diabetes mellitus with unspecified complications
I73.9 - Peripheral Vascular Disease, unspecified
E11.51 - Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene
What is E11.51 - Type 2 diabetes mellitus with diabetic peripheral angiopathy without gangrene
A 25 year old patient comes in today for an acute visit. She lost her inhalers during a recent move and is borrowing her boyfriend’s albuterol which doesn’t seem to be helping. On exam she is able to speak in short sentences and has diffuse wheezing. Symptoms improve with a nebulizer treatment in the office. She has severe asthma and has had ICU admissions in the past. Based on the documentation this is a correct diagnosis code
J45.51 - Severe persistent asthma with (acute) exacerbation
Your practice sees a patient today for Major Depressive Disorder and the patient remains stable without current symptoms (for >6months), and is tolerating their Wellbutrin without side effects. How would you help coach the clinician that saw the patient, on how to code the patient's depression based on the available evidence?
Major Depressive Disorder in Remission
Dr. Doe is complaing to you that there is NO benefit to coding Asthma to the highest specificity - as it makes no difference to them, or the care they deliver to the patient if the patient's asthma is billed as J45.909 - Asthma without complication vs J45.40: Moderate Persistent Asthma, without current exacerbation. What is an example of how accurate and complete documentation and coding of the patient's Asthma could benefit Dr. Doe or the patient.
Asthma codes are classified by severity (Mild Intermittent, Mild Persistent, Moderate Persistent, and Severe Persistent) and status (Exacerbation?). Always document and code to the highest level of severity known.
Benefits: Improved benchmark, Improved description of disease severity to stratify outreach and care management support, decreased prior authorization for maintenance control medications.
I saw Ms. Jones 6 months ago for her Dementia, then when I saw her back last week Dementia wasn't on the huddle - but she still has Dementia. She needs her Dementia managed - is the huddle broken if it's not showing up again? Can I code dementia, or do I need to wait until it is on the huddle again?
The daily huddle tool is a resource that shows conditions that have not yet been addressed this year that may need your clinical attention. A condition that has been billed this year will be removed from the huddle, but may still need ongoing management throughout the year.
A 60 year old patient with diabetes who is treated with long acting and prandial insulin. Her most recent Hemoglobin A1c from 3 weeks ago was 7.0% Review of her continuous glucose monitor shows frequent episodes of hypoglycemia in the middle of the afternoon. Her CGM alert is the only way she learns of these low blood sugars as she is otherwise asymptomatic. This is a potential way to code this patient's current condition.
What are:
E11.649 - Type 2 diabetes mellitus with hypoglycemia without coma
Z79.4 - Long term (current) use of Insulin
Ms. Jones is seen today for follow up on her atrial fibrillation - first diagnosed 2 years ago and for "clearance" prior to her upcoming cataract surgery. She is currently treated on Diltiazem and she is anticoagulated with Apixaban, which she is tolerating. On examination her heart rate is regularly regular and the 12-Lead EKG shows Normal Sinus Rhythm without evidence of Atrial Fibrillation.
Does she still have Atrial Fibrillation? How would you code it?
Atrial fibrillation (I48*) is still reported in patients that are not currently experiencing the erratic rhythm so long as the patient requires ongoing treatment to help control the rate/rhythm. Arrhythmia that occurred in the past and is no longer treated, such as postoperative AFib or that which has not recurred following a procedure, should be coded as “history of” (Z86.79).
A 55 year old patient comes in to follow up on emphysema. He is using inhalers as directed. He saw pulmonary about 2 months ago in November and was treated with prednisone for an exacerbation of COPD. What would the current best codes that describe the patients current clinical state?
1) n/a: Emphysema doesn't need to be coded as the pulmonologist coded it last 2 months ago
2) J44.9 - COPD, unspecified
3) J43.9 - Emphysema, unspecified
4) J44.1 - COPD with (acute) exacerbation
5) J45.901 - Unspecified asthma with (acute) exacerbation
J43.9 - Emphysema, unspecified
Rationale:
Emphysema is a progressive form of COPD and is more specific, therefore, it is appropriate to document and bill for emphysem
Sneaky Care Gap & Quality Question:
The patient you just saw had an elevated blood pressure of 176/88 when roomed by the Medical Assistant. When the BP was rechecked it improved to 128/70. What ways can you communicate to the healthcare payers that the blood pressure is controlled?
1) CPT-2 Codes
3074F – Systolic BP <130 mmHg
3078F – Diastolic BP < 80 mmHg
2) Capture subsequent BP in a discrete data field