Cardiac Conditions and Documentation Flashcards
7 cards from real CCDS practice questions. Tap to flip, then mark Knew It or Still Learning — missed cards come back until you master them.
Read the first 7 Cardiac Conditions and Documentation flashcards as text
A patient is admitted with chest pain and troponin elevation. The cardiologist documents 'demand ischemia due to sepsis.' How should the CDI specialist query this?
Answer: Query for acute MI type 2 due to supply-demand mismatch
Demand ischemia due to an underlying condition like sepsis classifies as Type 2 MI, which has its own ICD-10-CM code and impacts severity of illness.
Which documentation element is most critical when a physician records 'cardiomegaly' on imaging but the clinical note mentions 'dilated cardiomyopathy'?
Answer: Query to clarify whether cardiomegaly is a separate finding or the result of dilated cardiomyopathy
CDI specialists must query when imaging findings and clinical diagnoses conflict or overlap to ensure accurate and complete coding.
A patient with chronic systolic heart failure is admitted. The physician documents 'acute on chronic systolic heart failure' on day 2 but not in the discharge summary. What should the CDI specialist do?
Answer: Issue a query asking the physician to clarify and confirm the acute exacerbation in the discharge summary
All treating physician documentation can be used for coding, but a query ensures consistency and physician attestation in the final record.
When coding atrial fibrillation with rapid ventricular response (RVR), which statement is most accurate?
Answer: Atrial fibrillation with RVR is coded as atrial fibrillation; RVR is an integral manifestation and not coded separately
Rapid ventricular response is a manifestation of uncontrolled atrial fibrillation and is not assigned a separate code.
A patient undergoes cardiac catheterization revealing 70% LAD stenosis. The cardiologist documents 'significant CAD.' What should the CDI specialist consider?
Answer: Query to determine if the CAD involves native versus bypass graft vessels and the number of vessels
ICD-10-CM codes for CAD differentiate by vessel type (native/graft), number of vessels, and presence of angina, requiring specificity beyond 'significant CAD.'
Which of the following best describes the CDI impact of documenting 'acute systolic heart failure' versus 'acute heart failure, unspecified'?
Answer: Systolic specification increases diagnosis-related group (DRG) weight and reflects higher severity of illness
Specifying systolic versus diastolic heart failure maps to distinct ICD-10-CM codes that affect DRG assignment and quality metrics.
A patient is admitted post-cardiac arrest with ROSC (return of spontaneous circulation). The physician documents 'anoxic brain injury' and 'acute respiratory failure.' What is the CDI specialist's priority query?
Answer: Query to clarify the principal diagnosis and whether cardiac arrest or anoxic brain injury drives the admission
Determining the principal diagnosis among post-arrest complications requires physician clarification to ensure the condition that drove the admission is correctly identified.