Tracy Barret is the new coding section supervisor and wanted to do a quick assessment of her coding staff’s coding skills. Below is the discharge summary.
Ms. Albertino is a 69-year-old female with known coronary artery disease, status post CABG (coronary artery bypass grafting) on 5/15/XY, two-vessel disease, also aortic valve replacement. She is currently on Coumadin. The patient was admitted to the hospital 3 weeks ago for a myocardial infarction. She complained of shortness of breath and chest pain and was admitted as a result. She was not placed on any heparin drips or nitroglycerin drips. She was started on Isordil 30 mg b.i.d., as well as given nitro 50 mg t.i.d. and Norvasc 5 mg once a day. She states that she has been using nitro daily since discharge, and has chest pain at rest, at night time, or during exertion. She did not have a heart catheterization during this hospitalization, and was discharged secondary to cost.
OBJECTIVE: Vital signs: Blood pressure 154/69, weight 173, temperature 97.6, pulse 59, respirations 19. Oxygen saturation is 97% on room air. Neck is supple with no lymphadenopathy. Heart has regular rate and rhythm with an aortic click, no murmurs. Lungs are clear to auscultation bilaterally. Decreased breath sounds throughout. Abdomen is soft, nontender, nondistended with positive bowel sounds. Extremities: No peripheral edema; however, she has weak peripheral pulses bilaterally.
ASSESSMENT
- Unstable angina.
- Known coronary artery disease status post coronary artery bypass grafting.
PLAN: We will go ahead and order a resting EKG (electrocardiogram) for one week from today.
| Coder | Principal Diagnosis (ICD10CM) | Diagnosis | Diagnosis | Diagnosis | Diagnosis | CPT | Findings | ||
| Correct or Incorrect | MS DRG | ||||||||
| 1 | I21.3 | I25.110 | Z79.01 | Z95.1 | Z95.2 | 94760 | |||
| 2 | I25.110 | I21.3 | Z79.01 | Z95.1 | 94762 | ||||
| 3 | I21.3 | I25.110 | Z79.01 | Z95.1 | 94760 | ||||
| 4 | I21.3 | I25.110 | Z79.01 | Z95.1 | Z95.2 | 94750 | |||
| 5 | I21.3 | I25.110 | Z79.01 | Z95.1 | 94760 | ||||
For this assignment, prepare a summary of the audit with the following information:
- The correct codes for the scenario.
- determine the MS DRG based on the codes of each coder.
- Complete the table.
- Identify for each coder, any errors in the code assignment.
- Include the coding guideline not followed for any errors identified.
- Determine the coding accuracy rate (number of coders who coded the case correctly) divided by the number of coders.
- Prepare a two- to three-sentence summary of your findings.
Based on the findings of the above review, prepare a coding audit proposal in which you indicate the following:
- The number of charts to be coded.
- The frequency of the coding review.
- Your plan of action to address variations in coding.
