As the Inpatient Coding Supervisor of Moraine

As the Inpatient Coding Supervisor of Moraine Park Hospital, you are being asked to conduct a coding audit on three coders with a high rate of denied claims due to incorrect DRG assignment. Determine what data from the medical record needs to be reviewed in order to determine both coding accuracy, correct application of coding guidelines and DRG assignment. Audit the two coding cases below for DRG accuracy. You will need to access Clintegrity encoder to verify coding, guidelines and DRG: CASE 2: Patient: George McArthur MRN: 235487 Admission date – 3/1/xxxx Discharge date – 3/6/xxxx Discharge Summary: Mr. McArthur was admitted from the emergency room with chest pain, elevated BP and shortness of breath. He has a 30-year smoking history; currently smokes 1 pack of cigarettes a day. Initial diagnostic studies indicate an AMI. Patient was given an aspirin and put on oxygen. Chest pain subsided and he was scheduled for a cardiac catheterization. However, early the next morning Mr. McArthur went into cardiac arrest and was successfully resuscitated. He remained in the hospital for 4 and was discharged in stable condition and will be followed closely by his cardiologist. Discharge diagnosis: Cardiac Arrest, AMI CODER ASSIGNED CODES: Principal diagnosis: I46.9 – Cardiac Arrest -N Secondary Diagnoses: I21.3 – AMI -Y DRG 282 Acute Myocardial Infarction SCIENCE HEALTH SCIENCE NURSING NURSING 102

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