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chest pain and left heart catherization

Rebeka Posted Sun 15th of December, 2013 19:02:41 PM

A patient was admitted with chest pains. PMH includes hypertension, GERD, history of MI. His EKG indicated a acute myocardial infarction. He has a left cardiac cath, selective coronary angiogram and left ventriculogram They found complete obstruction of the LAD and intervention was successful with stents. His final diagnosis was acute posterolateral myocardial infarction, single vessel CAD. What would be the principal and secondary diagnosis and other codes used. Thank you!

SuperCoder Answered Mon 16th of December, 2013 08:44:16 AM

Stent …
92941-LD - Percutaneous transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction, coronary artery or coronary artery bypass graft, any combination of intracoronary stent, atherectomy and angioplasty, including aspiration thrombectomy when performed, single vessel

Assuming documentation supports this is a true diagnostic cath …
93458-26-59 - Catheter placement in coronary artery(s) for coronary angiography, including intraprocedural injection(s) for coronary angiography, imaging supervision and interpretation; with left heart catheterization including intraprocedural injection(s) for left ventriculography, when performed

Diagnoses:
1st: 410.51, Acute myocardial infarction of other lateral wall initial episode of care

414.01, Coronary atherosclerosis of native coronary artery

ICD-9 guidelines state, “Code all documented conditions that coexist at the time of the encounter/visit, and require or affect patient care treatment or management. Do not code conditions that were previously treated and no longer exist. However, history codes (V10-V19) may be used as secondary codes if the historical condition or family history has an impact on current care or influences treatment.”

So if the physician mentions taking the other diagnoses into account (e.g., in meds prescribed or in deciding how to proceed), it would be appropriate to report those, too.

Hx MI: 412, Old myocardial infarction
Hypertension: 401.9, Unspecified essential hypertension
GERD: 530.81, Esophageal reflux

.

Rebeka Posted Wed 18th of December, 2013 08:57:48 AM

What would the DRG be?

SuperCoder Answered Wed 18th of December, 2013 19:34:02 PM

218

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