Cardiac Conditions and Documentation Flashcards
6 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 6 Cardiac Conditions and Documentation flashcards as text
What is required to code cardiogenic shock in ICD-10-CM?
Answer: Explicit physician documentation of cardiogenic shock
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.
What defines a Type 2 MI (demand ischemia) in the context of CDI documentation?
Answer: MI caused by supply-demand mismatch without acute coronary plaque rupture
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.
Which statement best reflects ICD-10-CM documentation requirements for valvular heart disease?
Answer: All valve conditions require documentation of the specific valve, etiology, and severity when applicable
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.
What is the CDI specialist's primary role when an ICD (implantable cardioverter-defibrillator) is placed during an admission?
Answer: Verify documentation of the clinical indication and device type for accurate procedure and diagnosis coding
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.
A patient admitted with chest pain is definitively diagnosed with unstable angina. How should coding proceed?
Answer: Code unstable angina as principal; chest pain is not coded separately
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.
For a patient undergoing coronary artery bypass graft (CABG), which documentation elements are essential for ICD-10-PCS procedure coding?
Answer: Number of vessels bypassed and type of conduit used
CABG procedure codes in ICD-10-PCS require documentation of both the number of coronary arteries bypassed and the conduit type (arterial, venous, or combination) to assign the correct code.