Outpatient CDI clinical scenario: What’s your next move?

By Joanne Wilson, RN, ADN, CCDS

For this month’s CDI suggestion I wanted to offer up a clinical scenario for your consideration. I do encourage you to read it, and think about what you’d do. My suggestion follows.

A patient is scheduled for an appointment with their provider in 96 hours. As a prospective OP CDI, you review a previous encounter note and see the following documentation.

A/P: A 66-year-old patient with moderate early-onset Alzheimer’s was seen in the clinic for a six-month follow-up. The patient is independent except for bathing and dressing. Continue Keppra and Aricept.

CVA due to embolism of the cerebral artery- continue ASA

Provider Assigned Codes:

• G30.0- Alzheimer’s disease with early onset.
• F02.80- Dementia in other diseases classified elsewhere, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety.
• I63.40- CVA due to embolism of the cerebral artery

What are your next steps? Think about this for a moment before you skim ahead to the answer.

…

Done thinking? OK. Here’s what I came up with.

There are multiple opportunities on this ambulatory account:

1. Acute vs. Historical CVA—The OIG targets this as one of its top diagnoses. Many providers remain unaware of the documentation guidelines, and the automatic pull-through from the problem list continues to pose challenges.
2. Medications Without an Associated Diagnosis – This remains a standard gap, where medications are listed in the record without a corresponding diagnosis to justify their use. Why is the patient receiving Keppra?
3. Dementia Specificity – Ensuring the diagnosis includes proper staging and clinical detail is critical for accurate coding and quality reporting.

The primary goal of a prospective review is to support providers in recognizing outdated diagnoses, identifying changes in disease progression or staging, and ensuring the medical record accurately reflects the patient’s current condition and care.

What do you think—any other suggestions, something I missed? I welcome your input at joanne@norwood.com.