An 85-year-old female patient was admitted from a SNF for shortness of breath. Past medical history includes CHF DM type 1 and COPD. She has a stage lV sacral pressure ulcer; wound care consult was requested.
As the Inpatient Coding Supervisor of Moraine Park Hospital, you are being asked to conduct a coding audit on three coders with a high rate of denied claims due to incorrect DRG assignment. Determine what data from the medical record needs to be reviewed in order to determine both coding accuracy, correct application of coding guidelines and DRG assignment.
Audit the two coding cases below for DRG accuracy. You will need to access Clintegrity encoder to verify coding, guidelines and DRG:
CASE 1:
Patient: Judy Jones
MRN: 123478
Admission date – 2/15/xxxx
Discharge date – 2/15/xxxx
Discharge summary: An 85-year-old female patient was admitted from a SNF for shortness of breath. Past medical history includes CHF DM type 1 and COPD. She has a stage lV sacral pressure ulcer; wound care consult was requested.
Clinical Findings: Lab work showed an elevated BNP test. Pulmonary function test indicated that COPD was controlled. It was determined that SOB was due to a CHF exacerbation and treated with oxygen, vasodilators and loop diuretics with immediate improvement in severity. However, patient’s blood sugar was normal on admission but became elevated on day 2 of her admission. Once controlled, she was discharged back to the SNF.
Final Diagnosis: Diastolic heart failure acute on chronic, DM with hyperglycemia, COPD.
CODER ASSIGNED CODES with Present on admission indicators (POA):
Principal diagnosis:
R06.02 – Shortness of breath
Secondary Diagnoses:
I50.33 – Acute on chronic diastolic heart failure -Y
E10.65 – DM type 1 with hyperglycemia -Y
J44.1 – COPD exacerbation -Y
DRG
204 Respiratory Signs and Symptoms
CASE 2:
Patient: George McArthur
MRN: 235487
Admission date – 3/1/xxxx
Discharge date – 3/6/xxxx
Discharge Summary: Mr. McArthur was admitted from the emergency room with chest pain, elevated BP and shortness of breath. He has a 30-year smoking history; currently smokes 1 pack of cigarettes a day.
Initial diagnostic studies indicate an AMI. Patient was given an aspirin and put on oxygen. Chest pain subsided and he was scheduled for a cardiac catheterization. However, early the next morning Mr. McArthur went into cardiac arrest and was successfully resuscitated. He remained in the hospital for 4 and was discharged in stable condition and will be followed closely by his cardiologist. Discharge diagnosis: Cardiac Arrest, AMI
CODER ASSIGNED CODES:
Principal diagnosis:
I46.9 – Cardiac Arrest -N
Secondary Diagnoses:
I21.3 – AMI -Y
DRG
282 Acute Myocardial Infarction
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