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

For coding purposes, it is critical to link the acute respiratory failure to its cause. While the COPD is the underlying chronic condition, the pneumonia is the acute event that precipitated the decompensation. Linking the acute respiratory failure to the pneumonia is the most specific and accurate representation of the admission.

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

Mechanical ventilation is only coded when it is used for acute respiratory failure or other specific conditions. 'Airway protection' is not a codeable reason. The CDS must query to clarify the underlying medical necessity for the intubation, using clinical indicators to ask if a more specific diagnosis, like acute respiratory failure, is appropriate.

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

The clinical indicators (low PaO2 despite supplemental oxygen, tachypnea) are strongly suggestive of acute respiratory failure. The term 'hypoxia' is a symptom, not a definitive diagnosis. A query is needed to ask the physician if these clinical findings represent a more significant diagnosis like acute respiratory failure.

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

To support the 'acute on chronic' diagnosis, there must be documentation of an acute exacerbation or decompensation from the patient's baseline state. This is typically evidenced by an acute worsening of blood gases (e.g., a significant rise in pCO2 from baseline), increased respiratory distress, or a new precipitating event like pneumonia.

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

The term 'terminal extubation' or 'terminal wean' clarifies that the removal from the ventilator is part of the end-of-life process, not a failure to wean or a reflection of the quality of care. This distinction is important for quality metrics and accurately portraying the clinical circumstances.

CCDS - Certified Clinical Documentation Specialist Practice Test

CCDS - Certified Clinical Documentation Specialist Practice Test

FREE CCDS Respiratory Failure & Vents Questions and Answers