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

Cardiogenic shock must be explicitly documented by the physician; clinical indicators such as hypotension or vasopressor use cannot be used by coders to assign this diagnosis independently.

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

Type 2 MI results from a physiologic supply-demand mismatch (e.g., tachycardia, anemia, hypotension) rather than plaque rupture, and maps to a distinct ICD-10-CM code.

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

All valvular conditions in ICD-10-CM require documentation of the specific valve affected, etiology (rheumatic vs. non-rheumatic), and clinical severity to assign the most accurate code.

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

CDI must verify documentation of the clinical indication (e.g., LVEF ≤35%, sustained VT) and device type (single vs. dual chamber) to support accurate procedure coding and DRG assignment.

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

When a confirmed diagnosis is established, it is coded as principal and presenting symptoms integral to that diagnosis are not coded separately per ICD-10-CM guidelines.

CCDS - Certified Clinical Documentation Specialist Practice Test

CCDS - Certified Clinical Documentation Specialist Practice Test

CCDS Cardiac Conditions and Documentation 2