Monday, April 20, 2020

Type 2 Myocardial Infarctions

Last year, in an edition of “In the kNOW” was devoted to discussion of the various types of MIs.  With changes to the ICD-10-CM guidelines this year, I felt it important to review type 2 MIs.

First a word regarding type 2 MIs; this type of MI results from another condition which is placing the supply/demand of myocardial oxygenation into an imbalance.  These conditions may include: heart failure, shock, renal failure, anemia, or chronic obstructive pulmonary disease (COPD) to name a few. 

The guideline change for type 2 MIs that occurred in October had three components as you can see highlighted below. 

Type 2 myocardial infarction (myocardial infarction due to demand ischemia or secondary to ischemic imbalance) is assigned to code I21.A1, Myocardial infarction type 2 with the underlying cause coded first. Do not assign code I24.8, Other forms of acute ischemic heart disease, for the demand ischemia. If a type 2 AMI is described as NSTEMI or STEMI, only assign code I21.A1. Codes I21.01-I21.4 should only be assigned for type 1 AMIs.

The first, rather insignificant change was the correction of a typographical error.  The word “balance” which was describing ischemia was amended from “balance” to “imbalance”.  This just makes sense as ischemic imbalance would be indicative of a problem.

It is the next change that is very significant in this guideline change.  Here we see that there has been a change regarding how coding professionals are to sequence type 2 MIs.  The guideline specifies that the underlying cause is to be coded first.  Until the update in October, coders were able to sequence these conditions based on the circumstance of the admission, but not any longer.

Let’s look closer at the impact this could have for our facilities.

If a type 2 MI occurs as a result of COPD, we may have previously assigned the type 2 MI as principal diagnosis giving us a DRG of 282 and reimbursement of about $4,252.  Under the guideline change the COPD will have to be sequenced first, changing the DRG assignment to 190, with estimated reimbursement of about $6,696 or an increase of about $2,400.

However, if supraventricular tachycardia was the underlying cause of the type 2 MI, our DRG will shift from 281 and about $5,528 (when the type 2 MI was sequenced first) to 282 for the SVT now principal diagnosis and drop in reimbursement to $4,252.

It is obvious that while there is definitely going to be a financial impact associated with this new guideline change, that impact has the potential to be positive or negative.  Coding and CDI professionals must be diligent when coding for this condition and examining all documentation in order to identify the underlying cause for principal diagnosis selection.

The change is further reflected in the Tabular Index where a NOTE change occurred as shown below:

Delete  Code also the underlying cause, if known and applicable, such as:

Add      Code first the underlying cause, such as:

                        anemia (D50.0-D64.9)
                        chronic obstructive pulmonary disease (J44.-)
                        paroxysmal tachycardia (I47.0-I47.9)
                        shock (R57.0-R57.9)

Once again, a reminder that the changes that come in October are not just codes, but guidelines and notes, which we must be aware of as well.

Just a quick word about the final guideline change for type 2 MIs.  There was the addition of the word “If” in the final sentence.  This just clarifies that should a type 2 MI be described by the provider as a STEMI or NSTEMI, coding professionals are still to assign the type 2 MI code at I21.A1 only.  Acute MI codes are not to be coded for type 2 MIs.

Now you are In the

About the Author 

Dianna Foley, RHIA, CHPS, CCS  is OHIMA's Coding Education Coordinator. Dianna has been an HIM professional for 20 years. She progressed through the ranks of coder, department supervisor, and department director, to her current role as a coding consultant. 

She recently served as the program director for Medical Coding and HIT at Eastern Gateway Community College. Dianna earned her bachelor's degree from the University of Cincinnati subsequently achieving her RHIA, CHPS, and CCS certifications. She is an AHIMA Approved ICD-10-CM/PCS Trainer and a a presenter at regional HIM meetings and the OHIMA Annual Meeting.

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