The patient has a history of CAD and came to the ER complaining of chest pain. EKG and labs including troponin levels were performed. Nitroglycerin was administered and oxygen therapy initia
Discussion 8: Case Evaluation
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Case Information
You have agreed to accept a HIM student for their professional practice experience (PPE) at your facility. Today you are working on coding. You are giving feedback on the codes that the student assigned for the following scenario:
Patient John Smith, MR #121212, Acct #000633553
The patient has a history of CAD and came to the ER complaining of chest pain. EKG and labs including troponin levels were performed. Nitroglycerin was administered and oxygen therapy initiated. Results from the tests indicated the patient was having an ST-elevation anterior wall myocardial infarction (STEMI). The patient was admitted and taken to the catheterization lab for immediate single vessel angioplasty. Following the percutaneous coronary intervention, the patient was monitored continuously. Beta Blockers and Coumadin therapy were begun. The patient’s hypertension was addressed and he received medication for low potassium levels as well. His diabetes was managed by an oral hypoglycemic agent and diet with no significant issues during the admission. After four days, the patient was discharged home to continue his medication regimen and begin cardiac rehabilitation.
Codes assigned by student: R07.9, I10, E87.6, I25.10, I21.09, E11.9, Z79.84, 02703ZZ
Instructions
Read the case scenario fully.
Review the codes assigned by the student.
Re-code the case based on your own experience.
Explain your coding pathway(s) in detail by:
Justifying your codes.
Providing coding pathways for the re-coded case for all diagnoses and procedures.
Show your pathways by outlining the use of the index and tabular list, e.g. how does one look up the codes and then verify?
Based on what you have learned thus far, how do you feel the student’s coding would impact the organization’s reimbursement?
Hello Dear Course Hero Officials: The following question is asked by my professor, for your continued help please. Thank you
Respectfully
Teferi W.
Hello Teferi,
Good work on your recoding this case and your notation of the principal diagnosis of STEMI vs. chest pain. Again, nice analysis of the student’s codes and the need for resequencing.
Just a few thoughts regarding angina pectoris and STEMI. Based on coding guidelines, is there one code that combines the two? Likewise, take a look at the procedure code, are there two other procedure ICD-10-PCS codes that would be a better fit? I would also question the Z code as the patient is not coming in for those services specifically but this could be added to show the anticoagulant use.
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