CCDS Respiratory Failure & Vents 3

Question 1

A patient with acute exacerbation of COPD is placed on BiPAP in the ED and admitted to the ICU. Arterial blood gas shows pH 7.28, PaCO2 58, PaO2 54. Which diagnoses should be queried for in this scenario?

Accepted Answer

Acute-on-chronic respiratory failure (hypercapnic) and COPD exacerbation

Answer

The ABG values (pH 7.28, PaCO2 58, PaO2 54) indicate hypercapnic failure in a COPD patient, representing acute-on-chronic respiratory failure. CDI should query for both COPD exacerbation and acute-on-chronic respiratory failure.

Question 2

A CDI specialist reviews a case where a patient is extubated successfully on day 3 of mechanical ventilation. The physician documents 'respiratory failure, resolved.' The CDI specialist should:

Accepted Answer

Query to specify the type and chronicity (acute hypoxic, hypercapnic, or acute-on-chronic)

Answer

Even though respiratory failure resolved, it was an active, significant diagnosis during the stay that required mechanical ventilation. CDI should query for specificity (hypoxic versus hypercapnic, acute versus acute-on-chronic) because the specific code carries MCC designation. Resolved conditions that affected care during the stay are coded.

Question 3

Ventilator-associated pneumonia (VAP) requires documentation of which minimum timeframe on mechanical ventilation before pneumonia onset?

Accepted Answer

Pneumonia developing more than 48 hours after initiation of mechanical ventilation

Answer

VAP is defined by CDC and clinical criteria as pneumonia developing more than 48 hours after mechanical ventilation was initiated.

Question 4

In ICD-10-PCS, which structural feature distinguishes Section 5 ventilation codes from Section 0 medical and surgical codes?

Accepted Answer

Section 5 uses Duration and Function characters instead of a standard Approach character

Answer

Mechanical ventilation codes in ICD-10-PCS Section 5 use Duration and Function characters in positions where Section 0 codes use Body Part, Approach, and Device characters. There is no standard Approach character in Section 5 respiratory ventilation codes.

Question 5

A CDI specialist notices that a patient with acute respiratory distress syndrome (ARDS) is documented only as 'bilateral pneumonia' by the attending. What clinical documentation would BEST support querying for ARDS?

Accepted Answer

Berlin criteria: acute onset within 7 days, bilateral infiltrates not fully explained by cardiac failure, and P/F ratio 300 or below despite PEEP at or above 5 cm H2O

Answer

The Berlin Definition of ARDS requires: acute onset within one week of clinical insult, bilateral opacities on imaging not fully explained by effusions/collapse/nodules, respiratory failure not fully explained by cardiac failure or fluid overload, and decreased P/F ratio with PEEP at or above 5 cmH2O.

CCDS - Certified Clinical Documentation Specialist Practice Test

CCDS - Certified Clinical Documentation Specialist Practice Test

CCDS Respiratory Failure & Vents 3