Coding from cardiac cath/angioplasty report
A patient with NSTEMI was transferred from another facility after 2 day stay for cardiac cath. Cath report signed by MD states complete occlusion of RCA at ostial with collateral distally and basal inferior wall akinesis, LVEF 55% will treat medically.
Patient stayed 2 nights. Treated with plavix.
Coder states cannot code the MI or RCA occlusion, etc stating she cannot code diagnoses from the physician's cardiac cath report. Trying to determine why cannot code from signed cath report.
Coded as:
414.00 coronary atherosclerosis native vessel
411.1 Intermediate coronary syndrome
and the LHC & coronary arteriogram was coded
Does this sound correct?
Patient stayed 2 nights. Treated with plavix.
Coder states cannot code the MI or RCA occlusion, etc stating she cannot code diagnoses from the physician's cardiac cath report. Trying to determine why cannot code from signed cath report.
Coded as:
414.00 coronary atherosclerosis native vessel
411.1 Intermediate coronary syndrome
and the LHC & coronary arteriogram was coded
Does this sound correct?
Comments
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.412.9421
evanspx@sutterhealth.org
___________________________
A patient with NSTEMI was transferred from another facility after 2 day stay for cardiac cath. Cath report signed by MD states complete occlusion of RCA at ostial with collateral distally and basal inferior wall akinesis, LVEF 55% will treat medically.
Patient stayed 2 nights. Treated with plavix.
Coder states cannot code the MI or RCA occlusion, etc stating she cannot code diagnoses from the physician's cardiac cath report. Trying to determine why cannot code from signed cath report.
Coded as:
414.00 coronary atherosclerosis native vessel
411.1 Intermediate coronary syndrome
and the LHC & coronary arteriogram was coded
Does this sound correct?
In general, the coder can and should use diagnoses from op/procedure reports unless there is discrepancy between attending and cardiologist documentation in which case a query would be necessary.
This if from CC 1992 5th
Question:
A patient was transferred to Hospital B after six days treatment in Hospital A for a myocardial infarction (MI). The principal diagnosis on the medical record at Hospital B was listed as "coronary atherosclerosis" with "acute MI inferior wall" listed as a secondary diagnosis. A cardiac catheterization during the admission at Hospital B revealed severe disease in the right coronary artery with 75% narrowing in the left anterior descending artery. On transfer to Hospital B, the patient continued to receive treatment for the MI and continued to have angina. Wouldn't it be more correct to keep using code 410.41, Acute myocardial infarction of other inferior wall, as the principal diagnosis on the admission to Hospital B?
Answer:
[Note from 3M:
As of October 1, 1994, code 414.0 has been expanded to fifth digits to indicate specific site of coronary atherosclerosis.]
Yes, code 410.41 would be the principal diagnosis for the admission to Hospital B since the MI had not yet resolved. Code 414.0, Coronary atherosclerosis, would also be assigned as a secondary diagnosis.
Sharon Salinas, CCS
Health Information Management
Barlow Respiratory Hospital
2000 Stadium Way, Los Angeles CA 90026
Tel: 213-250-4200 ext 3336
FAX: 213-202-6490
ssalinas@barlow2000.org
Sharon Salinas, CCS
Health Information Management
Barlow Respiratory Hospital
2000 Stadium Way, Los Angeles CA 90026
Tel: 213-250-4200 ext 3336
FAX: 213-202-6490
ssalinas@barlow2000.org