A 62-year-old female with history of HTN, CAD, chronic cough and obesity is seen by her PCP. Which of the following treatment plans may result in a query?
A.
Diagnostic chest x-ray
B.
A visit with a nutrition specialist
C.
Order placed for hemoglobin A1c (HbA1c)
D.
Prescription written for the ACE inhibitor captopril
In outpatient CDI practice, a common reason to query is a mismatch between what is being evaluated/treated and what is explicitly documented as an active condition for the encounter. A diagnostic chest x-ray aligns with the already-documented symptom (chronic cough), and a nutrition specialist referral aligns with an established diagnosis (obesity); neither inherently suggests an undocumented condition. Prescribing captopril aligns with documented HTN management, so it generally would not create documentation ambiguity requiring clarification (even though ACE inhibitors can be associated with cough, the plan alone does not establish a new reportable diagnosis). In contrast, ordering an HbA1c often signals assessment for diabetes, impaired glucose regulation, or monitoring of known diabetes. Because diabetes is not listed in the history provided, the HbA1c order may prompt the CDI specialist to query whether the provider is evaluating a suspected or existing glycemic disorder, whether there is a diagnosis such as prediabetes/diabetes being addressed, and to ensure the record clearly supports the medical necessity and any reportable condition.
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