Wiki New to coding

[MrsAllen07]

Hello,

I need some help on a study that I am doing. I am trying to figure out what primary code and what secondary code to put in and the procedure code as well. If anyone can help that would be great.

A 51 y/o male was admitted through the ED complaining of substernal chest pain which occurred while he was mowing the lawn, not relieved with rest. Per H&P: On Lopressor for hypertension, moderate GERD controlled with Nexium, reports father had an MI in his 50s. The patient?s cardiac enzymes were elevated and an EKG indicated acute myocardial infarction. He was treated with IV heparin, O2, and taken emergently to the cath lab for left cardiac catheterization, selective coronary angiogram (Judkin?s technique) and left ventriculogram. The patient was found to have complete obstruction of the LAD and underwent successful intervention with two Cypher stents, no residual stenosis noted. Postop diagnosis: Acute posterolateral myocardial infarction, single vessel CAD. The patient?s recovery was uneventful and he was discharged home with the addition of Imdur to his regular medications.

Principal diagnosis code:
Secondary diagnosis code(s):
ICD-9-CM procedure code(s):

 

[klabent@yahoo.com]

MrsAllen07

Good Morning,

I am new to coding myself. I would like to follow this to see if I came up with the correct answers if you don't mind. I came up with the following.

ICD-9 786.51 Substernal Chest Pain
ICD-9 410.9 Myocardial Infarction
CPT 93452-LT

 

[mitchellde]

You would not code the chest pain since you have the definitive dx of Acute MI, therefore the acute MI would be the primary and Cad the secondary. There is not enough of a procedure note to advise on the procedure, however if you are coding for the ER you would not code the procure, only the EKG. So the correct answer depends on which provider you are coding for or if you are coding for the facility.

 

[MarcusM]

In general, you want to pick the most descriptive and accurate diagnosis code(s) possible to paint as complete a picture as possible of the patient's condition. Yes, chest pain was the CC, but the pain was due to the acute MI, and the diagnosis for acute MI gives a better picture of the patient's condition. If the doctors were not able to pinpoint the reason for the chest pain, then you could use chest pain as the primary diagnosis.

 

[mitchellde]

There is nothing in the note you provided to support any of the codes you have listed. Please advise as to how you chose your codes. I am not in the habit of just listing codes until I know you are on the correct path. If you tell me how you came up with your answer I can try to figure out how you went wrong.