Question

You are a coding supervisor at a local hospital. You have agreed to accept an HIM student for their professional practice experience at your facility. Today you are working on coding. You are giving feedback on the codes that the student assigned for the following scenario. Give your feedback to the student, tying your feedback to the Uniform Hospital Discharge Data Set and reimbursement and justify what the correct coding should be.

Patient: John Smith MR121212 Acct 000633553

Patient came into the ER complaining of chest pain. EKG and labs, including troponin levels, were performed. Nitroglycerin was administered and oxygen therapy initiated. Results of the tests indicated that the patient was having an anterior wall myocardial infarction. Patient was taken to the cath lab for immediate single vessel angioplasty. Following the percutaneous coronary intervention, the patient was admitted to the floor. He 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 well managed with medication and diet with no significant issues during the admission. After four days, the patient was discharged home to continue his medication regime and begin cardiac rehab.

Answer 1

Coding according to ICD-10, 5th edition (2018)

Chest pain, unspecified - R07.4

Acute transmural myocardial infarction of unspecified site - I21.3

Atherosclerotic heart disease - I25.1

Presence of coronary angioplasty implant and graft - Z95.5