CCDS Cardiac Conditions and Documentation 2

Question 1

What is required to code cardiogenic shock in ICD-10-CM?

Accepted Answer

Explicit physician documentation of cardiogenic shock

Answer

Blood pressure below 90/60 mmHg documented in nursing notes

Answer

Initiation of vasopressor therapy

Answer

Cardiac output below 2.2 L/min/m² on Swan-Ganz catheter

Question 2

What defines a Type 2 MI (demand ischemia) in the context of CDI documentation?

Accepted Answer

MI caused by supply-demand mismatch without acute coronary plaque rupture

Answer

MI caused by acute coronary plaque rupture with thrombosis

Answer

Chronic ischemic cardiomyopathy with prior infarction

Answer

Unstable angina with elevated troponin but no ECG changes

Question 3

Which statement best reflects ICD-10-CM documentation requirements for valvular heart disease?

Accepted Answer

All valve conditions require documentation of the specific valve, etiology, and severity when applicable

Answer

Mitral regurgitation requires the most specific documentation of all valve conditions

Answer

Only aortic valve conditions need etiology documented

Answer

Valve severity documentation is optional for code assignment

Question 4

What is the CDI specialist's primary role when an ICD (implantable cardioverter-defibrillator) is placed during an admission?

Accepted Answer

Verify documentation of the clinical indication and device type for accurate procedure and diagnosis coding

Answer

Review only the surgeon's operative note for completeness

Answer

Confirm the device is documented anywhere in the chart

Answer

No CDI review is needed for device implantation procedures

Question 5

A patient admitted with chest pain is definitively diagnosed with unstable angina. How should coding proceed?

Accepted Answer

Code unstable angina as principal; chest pain is not coded separately

Answer

Code chest pain as principal diagnosis, unstable angina as secondary

Answer

Code both chest pain and unstable angina as co-equal diagnoses

Answer

Code only the symptom since it was the admission reason

Question 6

For a patient undergoing coronary artery bypass graft (CABG), which documentation elements are essential for ICD-10-PCS procedure coding?

Accepted Answer

Number of vessels bypassed and type of conduit used

Answer

Surgeon attestation and operative time only

Answer

Number of vessels bypassed only

Answer

Post-operative ejection fraction measurement