cardiogenic shock and cardiac arrest

Scenario: Pt cardiac arrests out of hospital, CPR for 12 min, etc., brought to ER intubated and unresponsive. Pt hypotensive, started on pressors, cardiogenic shock documented. Pt expired later same day

There is an excludes 1 note for cardiac arrest and cardiogenic shock which directs us to code cardiogenic shock and not the arrest.

What is the pdx then? I would have coded the cardiac arrest if shock wasn't documented. I wouldn't say the shock is the underlying condition for the cardiac arrest, rather it is a result of the arrest? Thoughts?


  • edited June 2019
    Based off the explanation below, I would take the cardiogenic shock as the principal since that is what was present on admission and the patients cardiac arrest happened prior to admission.
    Though unresponsive, was the patient out of arrest upon admit? (I would imagine they resuscitated before transfer to inpatient). 

    The 2017 CDI Pocket Guide states:
    "Cardiac arrest in unlikely to be principal diagnosis when the patient is resuscitated and survives to be admitted. If the cause if known, such as myocardial infarction, the cause would be sequenced first. If the cause, such as ventricular fibrillation, was corrected prior to admission, it would not typically be the focus of the admission pursuant to OCG II.B and C (circumstances of admission, therapy provided). Likewise, cardiac arrest with unknown or undocumented cause would rarely be the focus of admission. 
    Often the consequences of cardiac arrest are the reason for admission and the most likely principal diagnosis. For example, a patient in cardiac arrest is resuscitated in the emergency room and admitted with respiratory failure (on a ventilator or not); respiratory failure would almost invariably be principal diagnosis as the focus of admission."

    Hope this helps!
  • Hi,

    I thought I have always learned that Shock can not be pdx. what caused the arrest?if unknown, I would think it would go to cardiac arrest? Any of the following? MI? arrythmia? PEA?Sepsis?

  • OSH cardiac arrest with return of spontaneous circulation….

    The Problem: The misconception in the PDX selection is when coders or CDI professionals assume that the PDX is the same as the reason the patient presents to the hospital.

    Ask this question:: Why was the patient admitted to acute inpatient care? ----outside hospital arrest resolved with return of spontaneous circulation but now (mitigating circumstances: other factors that may come into play and require a higher level of care ) –ie vent to support resp failure.  It may take the physician a day or two, or even the entirety of the patient’s stay, to determine the etiology of the cardiac arrest. Sometimes the physician simply cannot make this determination, and the symptom/manifestation remains the only diagnosis. When this happens mitigating circumstances that support the need for inpatient care.

    The Answer:::The co-equal PDX selection criterion - According to Coding Clinic for ICD-9-CM, Second Quarter 1990, p. 4: “When two or more diagnoses equally meet the criteria for principal diagnosis as determined by the circumstances of admission, diagnostic workup, and/or therapy provided (and the Alphabetic Index, Tabular List, or another coding guideline does not provide sequencing direction), any one of the diagnoses may be sequenced first.”

     SOMETHING TO THINK ABOUT: Patient comes in with syncope episode that resulted in a fall that resulted in fractured hip. Automatically we go with fractured hip as PDX.

    But if she did not have the syncope episode and not fallen there would not have been a fractured hip so using a certain argument –syncope should be the PDX.

    So why then do we code cardiac arrest as the PDX when we admit to ICU with respiratory failure and continue with “postresuscitation” care? 

    Irrespective of the initiating rhythm or cause of the cardiac arrest, the end result of the arrest is inadequate delivery of oxygenated blood to the tissues. This process, combined with the underlying cause of the arrest, result in a large number of changes within the body.

  • Re:  Cardiogenic shock is a ‘sign/symptom’ code, as such, the cause should be listed as the PDX if or when documented.  See Coding Guidelines regarding assignment of Principal Diagnosis.

    If a scenario in which the chart documents ‘cardiac arrest and cardigogenic shock, as stated above,  strive to discern and code as the PDX the CAUSE of the cardiac arrest.  If even after study the medical staff does not identify a cause for the cardiac arrest, it would then be the PDX, followed by the cardiogenic shock.  
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