Question

Are the coding assignments correct on the following scenario? 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

Answer 1

In consideration of coded details, the medical coding given in the scenario is accurate. The principal and secondary diagnosis codes correspond correctly to Judy's medical conditions. The interventions like vasodilators administration align with the diagnoses.

Step-by-step explanation:

In the given coding scenario, the coder assigned the codes correctly to the medical conditions specified. The principal diagnosis code R06.02 correctly corresponds to the main reason Judy was admitted, which was shortness of breath. The secondary diagnoses, related to diastolic heart failure (I50.33), DM type 1 with hyperglycemia (E10.65), and COPD exacerbation (J44.1) also appear to be correct and in accordance with the patient's final diagnoses. Notably, the interventions, including the administration of vasodilators, also align with these diagnoses.

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