MateViper1958
HIMC 2030-Advanced Coding Instructions: Determine the correct codes…
HIMC 2030-Advanced Coding
Instructions: Determine the correct codes for this case including ICD-10-CM diagnosis codes, ICD-10-PCS procedure codes, and MS-DRG codes. Then answer the questions at the end of the scenario.
Hint 1: Be sure you understand what was done at XYZ Hospital and what was done at this hospital. You’re coding for this hospital.
Hint 2: You will end up with four diagnosis codes and four procedure codes.
Scenario
History and Physical: The patient is a 67-year-old male who was transferred from XYZ Hospital, where he was admitted six days ago with chest pain, shortness of breath, elevated cardiac enzymes, and EKG changes indicating an anterolateral ST elevation myocardial infarction. He subsequently underwent a cardiac catheterization, which revealed significant four-vessel disease. He was transferred here for a coronary artery bypass procedure.
Past History: Type 2 diabetes (diet controlled), hypercholesterolemia, and status post appendectomy
Medications: See transfer list.
Allergies: None known
Physical Exam:
General: Normal appearing male in no acute distress
Cardio: Rate and rhythm regular
Lungs: Normal
Tests: Chest x-ray normal; EKG nonspecific T-wave changes
Impression and Plan: Anterolateral myocardial infarction, coronary artery disease, diabetes mellitus, and hypercholesterolemia; patient will undergo CABG tomorrow.
Operative Report
Preoperative Diagnosis: Coronary artery disease
Postoperative Diagnosis: Same
Procedure: CABG x 4; saphenous vein graft of obtuse marginal, diagonal artery, and posterior descending artery; left internal mammary artery to the left anterior descending artery. Cardiopulmonary bypass.
Description of Procedure: After obtaining adequate anesthesia, the patient was prepped and draped in the usual fashion. A primary median sternotomy incision was made, and the pericardium was opened. The left internal mammary artery was dissected as a pedicle using electrocautery and small hemoclips at the same time that the greater saphenous vein was harvested endoscopically from the left lower extremity. Cardiopulmonary bypass was instituted, and the patient was taken to a mild degree of hypothermia.
The aorta was cross-clamped, and electrical arrest effect was administered via cold blood cardioplegia. The saphenous vein graft was placed end-to-side with the posterior descending artery, and then a separate graft was placed to the obtuse marginal artery and finally a separate graft was placed to the diagonal artery. Each anastomosis was done with running 7-0 Prolene suture and verified no bleeders were present. The left internal mammary artery was subsequently brought through a subthalamic tunnel and placed end-to-side with the left anterior descending coronary artery.
Following completion of the grafts, warm blood cardioplegia was administered. During this time, two atrial and ventricular pacing wires were attached to the heart’s surface; in addition, mediastinal tubes also were placed. The cross clamps were released following this, and sinus rhythm returned spontaneously. The patient was weaned from cardiopulmonary bypass without incident.
After all grafts were checked for diastolic flow, which revealed no problems, the incisions were closed. The patient was taken to the recovery room in good condition and will be monitored in the intensive care unit for complications.
Progress notes:
Day 1: Patient progressing well; all vital signs are stable. Will transfer to step-down unit today.
Day 2: Heart rate stable and incision healing nicely. If patient continues to progress will be ready for discharge in a few days.
Day 3: Stable; patient ambulating in hallway without difficulty.
Day 4: Continues to progress in ambulation; ready for discharge tomorrow.
Day 5: Discharge patient today to follow up with myself next week.
Use the 3M encoder to find the ICD-10-CM diagnosis codes, ICD-10-PCS procedure codes, and the MS-DRG. Please list the code you picked along with its description (Example: K37, Unspecified appendicitis and 0DTJ4ZZ-Resection, Appendix, Percutaneous Endoscopic)
Can I please verify the information below?
At least just the codes?
Admitting diagnosis code:
Primary diagnosis code:
Secondary diagnosis codes:
Principal Procedure Code:
Secondary Procedure Codes:
MS-DRG:
Click the Options Menu then DRG Options to view options for the MS-DRG.
Which diagnosis code has the highest reimbursement amount based on the DRG?
How much is the reimbursement?
Exit out of the DRG Options.
What is the relative weight of this hospital stay?
Write a paragraph to describe why you chose the DRG you picked.
