FREE CCDS Respiratory Failure & Vents Questions and Answers

Question 1

A patient with end-stage COPD is admitted with pneumonia. The physician documents 'acute on chronic respiratory failure'. To ensure proper coding and sequencing, what should the CDS query for?

Accepted Answer

Clarification of the linkage, specifically if the acute respiratory failure is due to the pneumonia.

Answer

The patient's baseline oxygen saturation.

Answer

Whether the acute respiratory failure is hypoxic or hypercapnic.

Answer

The date of the patient's last pulmonary function test.

Question 2

A patient is placed on mechanical ventilation for 48 hours. The physician documents 'intubated for airway protection' in the progress notes. What is the most appropriate action for the CDS?

Accepted Answer

Query the physician to clarify the underlying medical reason for the intubation, such as acute respiratory failure.

Answer

No action is needed, as 'intubated' is sufficient for coding.

Answer

Inform the coder to add the procedure code for mechanical ventilation without a supporting diagnosis.

Answer

Query the physician to document the exact start and stop times of ventilation.

Question 3

A patient has a PaO2 of 58 mmHg on 4L nasal cannula and a respiratory rate of 28. The physician's assessment is 'hypoxia'. What type of query would be most appropriate?

Accepted Answer

A query presenting the clinical indicators and asking if a more specific diagnosis can be made.

Answer

A query asking the physician to document 'acute hypoxic respiratory failure'.

Answer

No query is needed as 'hypoxia' is a sufficient diagnosis.

Answer

A query asking to increase the patient's oxygen level.

Question 4

What is the key difference in documentation required for coding 'acute on chronic hypercapnic respiratory failure' versus 'chronic hypercapnic respiratory failure'?

Accepted Answer

Documentation of an acute worsening or decompensation from the patient's baseline respiratory status.

Answer

Documentation of any pCO2 level above 45 mmHg.

Answer

A physician's note simply stating the patient has a history of COPD.

Answer

The patient's use of home oxygen.

Question 5

A patient is on a ventilator for 6 days. On day 7, the family decides to withdraw care, and the physician documents 'terminal extubation'. Why is this documentation important?

Accepted Answer

It differentiates withdrawal of care from a failed weaning attempt, which can impact quality metrics.

Answer

It allows the hospital to bill for an extra day of ventilator management.

Answer

It is required for the death certificate.

Answer

It is the only way to stop the clock for counting ventilator days.

Question 6

A patient with acute respiratory distress is placed on BiPAP. To support a diagnosis of acute respiratory failure, the CDS should look for documentation of:

Accepted Answer

Clinical indicators such as tachypnea, accessory muscle use, and abnormal arterial blood gases.

Answer

A history of obstructive sleep apnea (OSA).

Answer

The specific BiPAP pressure settings.

Answer

The patient's report of sleeping better with the machine.