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Monthly CDI Scenario Discussion – August 2019

Topic: Cardiac Arrest – the Underlying Condition


  • 19 y/o female brought to ED by ambulance accompanied by boyfriend
  • The patient is found on presentation to the ED to be nonverbal, does not open eyes and has no motor responses
  • Boyfriend reports to ED physician that patient ingested a large amount of heroin and was feeling suicidal and depressed
  • ED physician documents as his final diagnosis: heroin overdose, probable suicide attempt, cardiac arrest, AMS
  • History and physical notes:
    • 19 y/o female admitted for cardiac arrest, heroin overdose, altered mental status, and shock
  • Tox screen + heroin / + opiates
  • Intubated for airway protection
  • Temp max 97.8, HR 55, RR 8 – 12, BP 72/46
  • Goes into shock in the ED and eventually has PEA arrest
  • Resuscitated and transferred to ICU on vasopressors
  • Next day, per nursing notes, GCS=5
  • Discharged 10 days later stating she was depressed because she lost her job; consented to inpatient psychiatric treatment

Question: What is the principle diagnosis in the scenario above? Any query opportunities?


The patient presents with a heroin overdose with subsequent cardiac arrest in the ED. Cardiac arrest is defined as cessation of cardiac activity with hemodynamic collapse.

Common causes:

  • Ventricular fibrillation due to MI (most common cause)
  • CHF
  • Hypertensive cardiomyopathy
  • Massive PE
  • Cardiac tamponade
  • Profound hemorrhage
  • Severe electrolyte imbalance
  • Intracranial hemorrhage
  • Medication and drug toxicity and poisons

UASI Recommends:

  • Query for toxic encephalopathy: patient nonverbal, does not open eyes, and has no motor responses in ED, and next day noted with GCS=5
  • Query MD for clarification on whether the overdose was intentional or accidental
  • Query the underlying cause of the cardiac arrest
  • Query for the etiology of shock

Documentation without query opportunities:

Principal diagnosis:
T40.1X2A Poisoning by heroin, undetermined, initial

Secondary diagnosis:
I46.9 Cardiac arrest, cause unspecified
R57.9 Shock, unspecified

DRG 917 Poisoning & toxic effects of drugs w/ MCC with RW=1.4737, GMLOS=3.5, SOI/ROM 3/2

Documentation with queries clarified:

Principal diagnosis:
T40.1X2A Poisoning by heroin, intentional self harm, initial

Secondary diagnosis:
I46.8 Cardiac arrest due to other underlying condition
R57.0 Cardiogenic Shock
G92 Toxic Encephalopathy

DRG 917 Poisoning and toxic effects of drugs with MCC RW=1.4737, GMLOS=3.5, SOI/ROM 3/3

CDI Educational Tips:

  • Always review EMS and ED records thoroughly, looking for cause of cardiac arrest
  • Cardiac arrest is a reportable secondary diagnosis. If known, the underlying cause should always be sequenced first
  • Cardiac Arrest I46.- is a MCC if the patient survives
  • Cardiac Arrest I46.- is not a MCC if the patient does not survive
  • For poisoning by heroin (T40.1-), there are four choices for intent:
    • Accidental, intentional self-harm, assault, and undetermined
    • Coding guidelines state: If the intent of the poisoning is unknown or unspecified, code the intent as accidental intent. The undetermined intent is only for use if the documentation in the record specifies that the intent cannot be determined
  • Shock unspecified is a CC, whereas, linkage of the shock to its cause results in a MCC

This is a short synopsis of a possible patient record and is not intended to be all inclusive. This is for educational purposes only and not intended to replace your institutional guidelines.