Read the following excerpt from a patient record that has been processed with co
ID: 245254 • Letter: R
Question
Read the following excerpt from a patient record that has been processed with computer-assisted coding (CAC) software.
1. Determine any areas of inaccuracy in the CAC identification.
2. Recommend corrections to the code assignment.
Mr. Reynolds is a 57-year-old white male admitted with chest pain. He developed pain while shoveloing snow outside his home. He ranks it an 8 out of 10 on the pain scale. He has arm or jaw pain. He has hyperlipidermia, and hypertension, on medication for both conditions. Last year, he suffered an acute myocardial infarction and was treated with stents. An EKG was performed and cardiac enzymes drawn. All results were normal. The patient exhibited the pain upon movement and palpation at the chondrosternal joint and a final diagnosis of sprain was determined.
Codes assigned by CAC:
R07.9, I21.3, R68.84, S23.421A, I10, E78.5
Explanation / Answer
Chest pain R07.9
Arm or jaw pain R68.84
Hyperlipidermia E78.5
Hypertension I10
Acute myocardial infarction I21.3
Chondrosternal joint sprain S23.421A
Additionally the following codes are to be added.
EKG 93005
Cardiac enzymes 82550
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