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7.4. The following documentation is from the health record of a...

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7.4. The following documentation is from the health record of a...

7.4. The following documentation is from the health record of a 66-year-old male patient. Discharge Summary 6/19/XX 

Admission Date: 6/28/XX 

Discharge Date: 

 

History of Present Illness: This patient is a 66-year-old male admitted on 6/19 because of unstable postinfarct angina. He underwent cardiac bypass surgery here 15 years ago. He did well until 1989, when he developed angina and underwent angioplasty with drug-eluting stents here. On 6/9, he was awakened with severe chest pain and was taken to a nearby community hospital where he was found to have a small anterior wall ST elevation myocardial infarction, with the CPK only slightly elevated.

 Because of this small infarction, he was referred here for consideration for further coronary arteriography. He was discharged from the hospital on June 16. On June 19. as the patient was walking from the vehicle to the office, he developed quite significant chest pain and was therefore admitted to rule out further infarction. 

 

Hospital Course: He was taken to the cardiac catheterization laboratory the day after admission. The right groin was prepped and draped using aseptic technique and the skin and subcutaneous tisue were locally anesthetized. The right femoral artery was entered and a coronary artery catheter was introduced over the guide wire. At that time, complete left heart catheterization, left ventricular cineangiography, coronary arteriography of multiple coronary arteries, and bypass visualization were performed using low osmolar contrast. We found that his left ventricle showed severe anterior hypokinesis, although it did still move. The left main coronary artery was narrowed by about 70 percent. 

The autologous venous bypass graft to the circumflex looked good, but the autologous venous bypass graft to the left anterior descending had a very severe stenosis in the body of the graft. Both of these previous bypass grafts were coronary artery bypass grafts using autologous saphenous vein graft material. There was a very large, marginal circumflex artery that had an orificial 80 percent stenosis. I felt that he was not candidate for angioplasty but should have bypass surgery. He was seen in consultation by Dr. Reed, who agreed with this, so he was taken to the operating room on 6/21 for that procedure. 
Using extracorporeal circulation and an open approach, the left internal mammary artery was anastomosed to the left anterior descending coronary artery and a venous graft was placed from the aorta to the marginal circumflex. Prior to the procedure a segment of the right greater saphenous vein was endoscopically harvested from the patient. It was found that the old venous graft to the main circumflex was in excellent condition with very soft, pliable walls, so that vessel was left intact. There were no complications of this surgery.

His postoperative course was singularly uncomplicated. He never had any arrhythmia problems; his wounds healed nicely. He had a tiny left pleural effusion that never needed to be tapped. He was walking about the ward participating in the cardiac rehab program at the time of discharge. 

 

Discharge Instructions: Discharge medications will simply be aspirin grains 5 q. d., Tylenol with Codeine 1 or 2 p.r.n. for pain, Lopressor 50 mg a day, and Colace, as necessary. He was instructed to contact his private physician upon return home for resumption of his medical care. He is to call me here at the medical center if there are any questions or problems that he wishes to discuss.

 Discharge Diagnoses:

 1. Unstable angina (intermediate coronary syndrome) 

2. Recent incomplete anterior wall myocardial infarction

 3. Coronary atherosclerosis, three vessel 

4. Successful double-bypass surgery 

                                 What are the correct codes for this admission? 

a. 125.110, 125.710, 121.09, Z95.5, 021009W, 02100Z9, 06BP4ZZ, 5A1221Z, 4A023N7, B2151ZZ, B2111ZZ, B2131ZZ 

b. 125.110, 125.710, 121.09, Z95.1, 021109W, 06BP4ZZ, 5A1221Z, 4A023N7, B2151ZZ, B2111ZZ, B2131ZZ 

c. 125.110, 125.710, N20.0, 122.0, Z95.5, 021009W, 02100Z9, 06BP4ZZ, 5A1221A, 4A023N7, B2151ZZ, B2111ZZ, B2131ZZ 

d. 125.110, 125.710, 125.2, Z95.5, Z95.1, 021009W, 02100Z9, 06BP4ZZ, 5A1221Z, 4A023N7, B21511Z, B2111ZZ, B2131ZZ

 

 

 

 

7.10. The following documentation is from the health record of a patient admitted with significant aortic and mitral valve stenosis. 

Surgery Date: 03/13/XX 

Preoperative Diagnosis: Severe aortic and mitral valve stenosis 

Postoperative Diagnosis: Severe aortic and mitral valve stenosis 

Operative Procedure: Aortic valve replacement using a synthetic valve prosthesis; mitral valve replacement using a 26-mm bovine pericardial valve prosthesis; transesophageal echocardiogram; cardiopulmonary bypass. 

Anesthesia: General endotracheal

Description of Procedure: Patient brought to the OR and placed on the OR table in the supine position. Arterial line and Swan-Ganz catheter were placed, general endotracheal anesthesia induced, and the patient prepped and draped in usual fashion. Transesophageal echocardiogram of the heart and aorta was then performed. 

 

Next the chest was opened through a midline median sternotomy incision. The patient was heparinized and aortic and single right atrial cannules were inserted in the usual fashion. Retrograde cardioplegia line was placed through the right atrium in the coronary sinus. The patient was next placed on cardiopulmonary bypass and cooled to 27 degrees centigrade. During the cooling process, the aorta was cross-clamped and 1000 ml of cold cardioplegic solution was given. Inspection of the mitral valve revealed a severely diseased mitral valvular apparatus with calcification in the annulus. A few of the secondary and primary chordae were able to be preserved but the entire anterior leaflet was removed along with decalcifying the annulus. 2-0 Ti-Cron pledgeted sutures were then placed circumferentially in the annulus. Next a 26-mm bovine pericardial valve prosthesis was seated and sutures were placed through the sewing ring of the valve. The atriotomy was closed using double row of 4-0 Prolene sutures. 

 

Transverse aortotomy was then performed and inspection of the aortic valve revealed a trileaflet aortic valve. Excision of the three leaflets was then carried out. The annulus was sized and found to accommodate a synthetic valve prosthesis. Next 2-0 Ti-Cron simple sutures were placed circumferentially in the annulus and then through the sewing ring of the valve. The valve was seated, sutures were tied and there was good seating of the valve. The aortotomy was then closed using double row of 4-0 Prolene sutures. 

 

A de-airing cannula was placed in the ascending aorta and the heart was filled with blood to remove the air. While the lungs were ventilated with the patient in head-down position, light pressure was applied to the carotids. The aorta cross-clamp was removed. The patient was then rewarmed to 37 degrees centigrade. Once the patient was rewarmed with adequate cardiac output and pulse, was weaned from cardiopulmonary bypass. The aortic and right atrial cannulas were removed and protamine was administered. Following adequate hemostasis, the entire mediastinum was irrigated with copious amounts of warm antibiotic solution. Two mediastinal chest tubes were placed for postoperative drainage. A single ventricular pacing wire was placed. Sternotomy was then closed in standard fashion after all instrument and sponges were accounted for. The patient was then taken to the cardiac postprocedural intensive care unit in stable condition. 

Which of the following is the correct code set for this inpatient procedure? 

a. 108.0, 02RF0JZ, 02RG08Z, 5A1221Z 

b. 108.0, 02RFOJZ, 02RG08Z, 5A1221Z, B24BZZ4 

c. 105.0, 106.0, 02RF0JZ, 02RG08Z, 5A1221Z, B24BZZ4 

d. 135.0, 105.0, 02RF0JZ, 02RG08Z, B24BZZ4 
 

7.14. This 56-year-old female was admitted for resection of an adrenal mass. The patient has had hypertension and palpitations of several years' duration treated with Toprol under good control. Ultrasound was done in consideration of the possibility of a mass, and catecholamine studies have been normal, A 4- to 5-cm right adrenal mass was identified. Dr. White had obtained a 24-hour urinary free cortisol, ACTH, and short suppression tests, all of which confirmed the presence of Cushing's syndrome. The patient was not diabetic. She did report weight gain, some shift in body configuration, and easy bruising of several years' duration. The easy bruising was identified on examination in the hospital. 

 

Surgery: A 5-cm, well-circumscribed round cortical tumor was resected from the adrenal gland via an open approach. Pathology report confirmed that the tumor was benign. 

 

Allergies: No known drug allergies

 

 Medications on Discharge: Hydrocortisone, rapidly tapering dose, currently on 40 mg daily; Toprol 50 mg q. a.m.; Prevacid 30 mg q. d.; Lipitor 10 mg q. a.m.; Prempro 0.625/2.5. 

 

Physical Exam: Vital signs stable. HEENT: Sclerae and conjunctivae clear. Neck: Supple. No palpable thyroid. Lungs: Somewhat decreased breath sounds currently. There is mild splinting with deep breathing. Abdomen: Tenderness in the incision area. She has active bowel sounds at this time. Extremities: No definite bruises currently. No edema noted. 

 

Discharge Diagnosis: Right adrenal tumor with Cushing's syndrome secondary to tumor. 

 

Plan: The patient appears to have tolerated the surgery well. She will require steroid replacement. Excess cortisol output is presumed entirely due to her tumor, and her ACTH was suppressed previously. As with exogenous steroid therapy, there will be contralateral adrenal suppression. The patient will be tapered rapidly to replacement hydrocortisone levels. We will try the remaining hydrocortisone withdrawal over the next 6 months or so, depending on her ACTH and cortisol responses. She is discharged to home with follow-up in my office in 1 week. 

Which of the following is the correct code set for this hospitalization? 

a. D44.11, E24.8, 110, R00.2, 0GB30ZZ 

b. C74.01, 10, R00.2, OGT30ZZ 

c. D35.01, E24.8, 110, R00.2, OGB30ZZ 

d. D35.01, E24.8, OGB30ZZ

 


 

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