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Original Question

The following documentation is from the health record of a cardiac service patient. DISCHARGE SUMMARY: Admit Date: 01/09/2022 Discharge Date: 01/12/2022 ADMITTING DIAGNOSIS: Coronary Artery Disease (CAD) FINAL DIAGNOSIS: 1. Coronary Artery Disease (CAD) 2. Long QT Syndrome 3. Hypertensive Heart Disease 4. History, Family, Sudden Cardiac Death PROCEDURES: 1. Percutaneous Transluminal Coronary Angioplasty with Stent Insertion (01/10/2022) 2. Permanent Dual Chamber Pacemaker Insertion (01/09/2022) HISTORY OF PRESENT ILLNESS: The patient is a 50-year-old female who was admitted to another hospital on 01/08/2022 after experiencing unexplained fainting and fluttering feeling in her chest. She thought her heart was “beating too fast”. Her father died of sudden cardiac death at age 52. This family history may indicate a genetic characteristic of her heart disease. At the first hospital, the patient was found to have an abnormal EKG with a long QT syndrome demonstrated and abnormal results of a Holter Monitor study. There she underwent a cardiac catheterization, showing the presence of severe two-vessel coronary artery disease. The patient does not have any history of a CABG in the past. The patient also is known to have hypertensive heart disease. She was transferred to our hospital to undergo a percutaneous transluminal angioplasty and further diagnosis and treatment of the Long QT syndrome. PHYSICAL EXAMINATION: Vital signs were abnormal with a pulse of 50 and blood pressure of x100/85. HEENT: PERLA: faint carotid bruits. Lungs: Clear to percussion and auscultation. Heart: perceived rhythm was abnormal. Extremities and abdomen were negative. HOSPITAL COURSE: To manage the patient’s Long QT syndrome, a permanent dual chamber pacemaker with atrial and ventricular leads was implanted on 01/09/2022. An incision was made into the left chest wall with the dual chamber pacemaker being placed in the subcutaneous pocket. Next, a small incision was made in the skin, and the leads were percutaneously passed into the right ventricle and right atrium. On 01/10/2022, the patient underwent a PCTA of both the left anterior descending artery (LAD) and the right coronary artery (RCA). Before the PCTA, but during the same procedure, she was found to have severely calcified arteriosclerotic plaque in the LAD. An atherectomy was performed in the LAD using the Diamondback orbital atherectomy technique system. When the lesion was removed, a drug- eluting stent was deployed in the LAD without complications and good results were obtained. The second vessel (RCA) did not require a stent. Postoperatively, the patient was stable and was subsequently discharged home. The patient’s hypertensive heart disease was managed and monitored during the hospital stay and the patient continued taking her normal medications for her conditions. Code the following: 1 point – Admitting Diagnosis: (1 code) (No POA modifier) 2 points – Principal Diagnosis: (1 code) (include POA modifier) 8 points – Secondary Diagnoses: (4 codes) (include POA modifiers) 1 point – Principal Procedure: (1 code) (PCS code) 5 points – Secondary Procedures: (5 codes) (PCS codes) EXTRA CREDIT – Enter the MS-DRG code in Question 2

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