Certified Documentation Improvement Practitioner (CDIP) — Question 15

A patient presented with shortness of breath, elevated B-type natriuretic peptide, and lower extremity edema to the emergency room. During the hospitalization, a cardiac echocardiogram was performed and revealed an ejection fraction of 55% with diastolic dysfunction. The patient's history includes hypertension (HTN), chronic kidney disease (CKD) (baseline glomerular filtration rate 40) and congestive heart failure (CHF). The clinical documentation integrity practitioner (CDIP) has queried the physician to further clarify the patient’s diagnosis. Which response provides the highest level of specificity?

Answer options

• A. Acute CHF with hypertensive renal disease, CKD 3
• B. Acute diastolic CHF with HTN and CKD 3
• C. Acute on chronic diastolic CHF with hypertensive renal disease, CKD 3
• D. Acute on chronic systolic CHF with hypertensive renal disease, CKD 3

Correct answer: C

Explanation

The correct answer, C, provides the highest specificity by indicating that the patient has acute on chronic diastolic CHF, which aligns with the echocardiogram findings of diastolic dysfunction. Options A and B do not capture the chronic aspect of the patient's condition, while option D incorrectly identifies the type of heart failure as systolic, which is not supported by the echocardiogram results.