also be aware that the treatment for a Type 2 MI will be directed
to the underlying cause. It should be noted that the term NSTEMI
should be used exclusively when documenting a Type 1 MI, and if
the provider documents NSTEMI Type 2 then code I21. A1 should
be used, as the MI type takes precedence over NSTEMI. The sequencing of Type 2 MI and its underlying cause is dependent on
the circumstances of admission. Coding and CDI professionals
should keep in mind that a Type 2 MI is frequently a secondary
diagnosis, and resource consumption/treatment will be directed
at the underlying cause or the principle diagnosis.
Non-MI Troponin Elevation
Patients may present with elevated troponin levels due to numerous cardiac or systemic factors such as defibrillation from automatic implantable cardioverter-defibrillator, stroke, or myocarditis.
The fourth universal definition of MI utilizes the term myocardial
injury without infarction for these types of pathophysiological origins of troponin elevation. Currently, this term does not exist in
ICD-10-CM. The current code set for myocardial injury refers to a
traumatic code such as contusion or laceration. Ideally, providers
should utilize the term “Non-MI Troponin Elevation due to [under-lying cause]” in this clinical scenario. Documentation of “Non-MI
troponin elevation” will code to ICD-10-CM, Chapter 18, Symptoms, Signs and Abnormal Clinical Laboratory Findings, Not Elsewhere Classified4 and the underlying cause will also be coded. Other causes of Non-MI Troponin Elevations include acute congestive
heart failure, end-stage renal disease, pulmonary embolism, sepsis,
rhabdomyolysis, intracranial hemorrhage, and trauma.
Education and Documentation Challenges
It is the duty of coding and CDI professionals to educate, query,
and re-educate providers to achieve the appropriate documentation habits for coding and reporting. Throughout health information management professional’s (HIM’s) endeavors to achieve desired goals, HIM must remember providers are here to take care of
patients and sometimes view coding and CDI efforts as intrusive.
However, HIM is ultimately responsible for making sure conditions are coded and reported accurately. Provider buy-in is a necessity to make this or any documentation endeavor a success.
Education Leads to Strong Coding, CDI
As demonstrated throughout this article, there are many red
flags when dealing with the accurate coding and reporting of
MIs and Non-MI troponin elevations. The key element of appropriately coding and reporting these conditions is education.
Having a strong education component for coding professionals,
CDI professionals, and providers is essential to ensure a good
understanding of the coding and clinical differences between
these diagnoses. According to ACC, having this knowledge will
facilitate the education of providers on documentation specifics. This will ultimately improve patient outcomes, quality reporting, and reimbursement for all involved. ¢
A special thank you is extended to Dr. Thad Waites, MD, MACC,
THE FOLLOWING LISTS key elements needed for identifying the specific type of MI and non-MI Troponin Elevations
for appropriate documentation and reporting.
Troponin elevation alone, or even a rise and fall alone, is not
diagnostic of acute myocardial infarction.
Diagnosis of Type 1 or Type 2 MI requires ischemic indicators be present:
Signs/symptoms of ischemia (e.g., chest pain)
Ischemic electrocardiogram changes
Imaging evidence of ischemia (e.g., ischemic perfu-sion defect, or new wall motion abnormality)
Diagnosis is usually confirmed by coronary angiography
Type 1 STEMI
Cause: Acute Coronary Thrombus
Treatment: Early Reperfusion Therapy
Documentation: STEMI of vessel or myocardial segment
Type 1 NSTEMI
Cause: Plaque rupture/erosion
Treatment: IV Heparin, early Cath/PCI, etc.
Type 2 MI
Cause: Ischemic imbalance due to supply/demand mismatch
Treatment: Treat underlying cause. IV Heparin, antiplate-let agents, Cath/PCI often not indicated and may even
Documentation: Type 2 MI due to_______
Non-MI Troponin Elevation
Cause: Non-ischemic mechanism (cardiac stretch, direct
injury, or other unclear mechanism as in ESRD)
Treatment: Underlying cause or no treatment
Documentation: Non-MI troponin elevation due to______
Other Cardiac Types
Type 3 MI (Sudden Cardiac Death)
Type 4 MI (MI due to PCI)
Type 5 MI (MI due to CABG)
AMI Unspecified should be avoided
The Clinical Picture for Correct MI
and Non-MI Designation
Quiz ID: Q1939007 | EXPIRATION DATE: JULY 1, 2020
HIM Domain Area: Clinical Data Management
Article—“Red Flags for Myocardial Infarctions Coding and CDI”
Review Quiz Questions and Take the Quiz Based on
this Article Online at https://my.ahima.org/store
Note: AHIMA CE quizzes have moved to an online-only format.
Continued on page 58