CCDS Cardiac Conditions and Documentation 4

Question 1

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?

Accepted Answer

Query for acute MI type 2 due to supply-demand mismatch

Answer

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.

Question 2

Which documentation element is most critical when a physician records 'cardiomegaly' on imaging but the clinical note mentions 'dilated cardiomyopathy'?

Accepted Answer

Query to clarify whether cardiomegaly is a separate finding or the result of dilated cardiomyopathy

Answer

CDI specialists must query when imaging findings and clinical diagnoses conflict or overlap to ensure accurate and complete coding.

Question 3

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?

Accepted Answer

Issue a query asking the physician to clarify and confirm the acute exacerbation in the discharge summary

Answer

All treating physician documentation can be used for coding, but a query ensures consistency and physician attestation in the final record.

Question 4

When coding atrial fibrillation with rapid ventricular response (RVR), which statement is most accurate?

Accepted Answer

Atrial fibrillation with RVR is coded as atrial fibrillation; RVR is an integral manifestation and not coded separately

Answer

Rapid ventricular response is a manifestation of uncontrolled atrial fibrillation and is not assigned a separate code.

Question 5

A patient undergoes cardiac catheterization revealing 70% LAD stenosis. The cardiologist documents 'significant CAD.' What should the CDI specialist consider?

Accepted Answer

Query to determine if the CAD involves native versus bypass graft vessels and the number of vessels

Answer

ICD-10-CM codes for CAD differentiate by vessel type (native/graft), number of vessels, and presence of angina, requiring specificity beyond 'significant CAD.'

CCDS - Certified Clinical Documentation Specialist Practice Test

CCDS - Certified Clinical Documentation Specialist Practice Test

CCDS Cardiac Conditions and Documentation 4