Wiki Inpatient Coding - The following documentation

[jticbs]

Here is the next case....

The following documentation is from the health record of a 66 year old male patient.
The patient is a 66 year old man admitted on 09/20/10 because of severe chest pain. He had previously undergone a cardiac bypass at this hospital 10 years ago for an AMI at that time. On 09/20 he was awakened from his sleep with severe chest pain and was brought here to the hospital where it was determined he had had a NSTEMI. Because of this current AMI and his previous cardiac history it was decided he should have a cardiac catheterization. In addition, the patient is also being treated with medications at home for hypertension, hyperlipidemia, and diabetes.
The patient was taken to the Cath lab where a left heart catheterization, ventriculogram, coronary angiography using a Judkins catheter, and bypass visualization was performed.
The results of the catheterization showed: left ventricle had severe anterior hypokinesis , the left main coronary artery was narrowed by 70%, the bypass to the circumflex looked good, but the venous bypass to the left anterior descending had a very severe stenosis in the body of the graft. There was a very large, marginal circumflex artery that had an orificial 80% stenosis also.
It was felt that the patient was not a good candidate for angioplasty but he should have bypass surgery.
Using extracorporeal circulation, the left internal mammary artery was anastomosed to the left anterior descending coronary artery and a saphenous graft was placed from the aorta to the marginal circumflex. It was found that the old venous graft to the main circumflex was in excellent condition. There were no complications of this surgery. The patient had an uneventful and uncomplicated hospital stay. He was discharged on the fourth day after his surgery.

Here are my answer:
Admitting DX: 786.50 POA Y
Principle Dx: 410.71 POA N
414.00 POA Y
412 POA Y
401.9 POA Y
250.00 POA Y
272.4 POA Y
Procedure: 36.11, 36.15, 39.61, 37.22, 88.53, 88.56

Let me know if there is any missing code(s). Thanks.

 

[Daniel Rowden]

The NSTEMI was present on admission. Remember that just because it was discovered after admission that he had one doesn't mean it wasn't there on admission. The clearly state he "had had a NSTEMI" which we know is the source of his chest pain. Infections, diarrhea, vomiting, fever, leukocytosis, respiratory failure, MIs, and/or complications/misadventures are going to be your most common things with a POA of no, however, most of the time these will be very easy to tell in records. They often say something about the time or "developed" during the stay like "the patient developed a fever and nausea last night" just remember that many conditions can easily be discovered during the stay but they were already there like a mass in the lungs incidentally found on on a CT.



Daniel Rowden CCS, CPC-H