Correct Instructions: Based upon the info that is given in the instructions, 1 there are no correct answers, 2 you can’t a MS-DRG from a CPT code. Just choose the one you think is correct and why. Instructions have errors made by the institution.
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
1. Unstable angina.
2. 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.
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