This case study challenges you to apply your knowledge of clinical terminology and coding principles to a

real$-$world medical scenario. It involves understanding the patient's medical history, diagnosing

conditions, assigning procedure codes, and accurately coding prescribed medications. Students would

need to refer to$/$search available references for the ICD$-10-$CM$,$ CPT$,$ and HCPCS Level II coding manuals

to complete the tasks successfully.

Demographic Data

Patient Name: Saleh Mohamed Salem Saeed Ahmad

Date of Admission: August $15,2023$

Age: $45$

Gender: Male

Diagnosis: Acute Myocardial Infarction $($AMI$)$

Medical History:

Saleh Mohamed has a history of hypertension and hyperlipidemia. He was presented to the emergency

department with severe chest pain, radiating to the left arm and jaw. An electrocardiogram $($ECG$)$

revealed ST$-$segment elevation indicative of an acute myocardial infarction. The patient was immediately

taken for cardiac catheterization, which confirmed a complete blockage in the left anterior descending

artery. An emergency percutaneous coronary intervention $(PCl)$ was performed, and a drug$-$eluting stent

was placed to restore blood flow.

Treatment:

Percutaneous Coronary Intervention $($PCl$)$ with drug$-$eluting stent placement

Aspirin $325mg$ daily

Clopidogrel $75mg$ daily for one year

Atorvastatin $40mg$ daily

Metoprolol $50mg$ twice daily

Nitroglycerin sublingual as needed for chest pain

Your Tasks:

Assign the appropriate ICD$-10-$CM code for the patient's primary diagnosis.

Identify the CPT code for the percutaneous coronary intervention $($PCI$)$ procedure.

Assign ICD$-10-$CM codes for the patient's hypertension and hyperlipidemia.

Determine the appropriate HCPCS Level II code for the drug$-$eluting stent used during the PCI.

Assign CPT codes for the medications prescribed to the patient.

What are the estimated cost of this case with references & justification?

Describe the role of the following's professionals in this case and their responsibilities

The Clinical coder

The accountant

The physician

Your Role as Healthcare administrator in Quality Unit

The Pharmacist