review] Upon retrospective review of a patient visit 2 weeks prior, a CDI specialist notes physician documentation stating the following: “Sick Sinus Syndrome in 2016 s/p pacemaker placement. Latest EKG shows normal paced rhythm.” There are no codes noted for Sick Sinus Syndrome or the pacemaker. Which of the following is the BEST course of action for the CDI specialist?

Based on the documentation, the pacemaker status meets the criteria for reporting in an outpatient setting. The note "Latest EKG shows normal paced rhythm" represents an evaluation of the device during the visit. However, the Sick Sinus Syndrome is documented as a past medical history ("in 2016") with no indication that it was monitored, evaluated, assessed, or treated (MEAT) during the current encounter. Therefore, only the condition that was actively addressed, the pacemaker status, is reportable for this visit. The CDI specialist's best action is to ensure the accurately supported code is captured.

B. This option uses incorrect terminology ("amend the codes") and assumes Sick Sinus Syndrome is reportable without supporting documentation, which would necessitate a query first.

C. This is incorrect because it presumes Sick Sinus Syndrome is reportable. Educating a provider to code something not supported by MEAT criteria in the visit's documentation is inappropriate.

D. The CDI specialist's role is to clarify documentation, not to direct billing. Re-billing would only be appropriate after documentation is clarified and codes are accurately assigned.

1. AHIMA. (2019). Outpatient CDI and Clinical Validation. Journal of AHIMA, 90(6), 42-45. This article discusses the importance of MEAT criteria for reporting chronic conditions in the outpatient setting.

2. ACDIS. (2019). Position Paper: Queries in Outpatient CDI. Section: "When to Query," pp. 4-5. This paper emphasizes that conditions mentioned as history require evidence of management (MEAT) in the current encounter to be reportable.