Type 2 MI
We have recently developed clinical indicators and query format for elevated tropinin (we worked in conjunction with our cardiologists). One of the choices in the query is AMI type 2 (myocardial infarction d/t ischemia or supply/demand mismatch). As a result, we are getting the diagnosis of AMI type 2 (subendocardial injury).
Our coders are at a fork in the road, so to speak, as to whether to take this as PDX or as an MCC.
The question is, does the type 2 AMI carry the same weight as the type 1 AMI (myocardial infarction due to plaque rupture, overriding other cardiovascular diagnoses?.
Does anyone have any experience with the coding of diagnosis AMI type 2?
Thanks,
Gail Eaton RN PCCN CDS
St. Joseph Health, Eureka, Ca
Our coders are at a fork in the road, so to speak, as to whether to take this as PDX or as an MCC.
The question is, does the type 2 AMI carry the same weight as the type 1 AMI (myocardial infarction due to plaque rupture, overriding other cardiovascular diagnoses?.
Does anyone have any experience with the coding of diagnosis AMI type 2?
Thanks,
Gail Eaton RN PCCN CDS
St. Joseph Health, Eureka, Ca
Comments
Email me your email address and/or phone number.
Dorie Douthit RHIT,CCS
ddouthit@stmarysathens.org
Clinical Documentation Specialist/HIM
707-445-8121 ext 7555
Gail.Eaton@stjoe.org
Gail Eaton RN PCCN CDS
Clinical Documentation Specialist
St Joesph Health
2700 Dolbeer, Eureka, Ca, 95501
Office: 707-445-8121 ext 7555
Cell: 707-267-0279
TGIF
Gail Eaton RN PCCN CDS
Clinical Documentation Specialist
St Joseph Health
2700 Dolbeer, Eureka, Ca, 95501
Office: 707-445-8121 ext 7555
Cell: 707-267-0279
From a coding perspective, there is not a ICD9-CM code that differentiates between AMI type 1 or AMI type 2. We were running into the issue of all the physician was documenting was "supply/demand mismatch" and having to query for MI. Thankfully with some discussion with cardiology this has become a non-issue for us.
Dorie
Tiffany, I've attached our template for electronic query. Feel free to use it as you need.
Gail Eaton RN PCCN CDS
Clinical Documentation Specialist
St Joesph Health
2700 Dolbeer, Eureka, Ca, 95501
Office: 707-445-8121 ext 7555
Cell: 707-267-0279
Don
Gail Eaton RN PCCN CDS
Clinical Documentation Specialist
St Joesph Health
2700 Dolbeer, Eureka, Ca, 95501
Office: 707-445-8121 ext 7555
Cell: 707-267-0279
We were struggling with the same issues re: supply/demand mismatch MI's at my facility and it's effects on core measures. Our Cardiologist offered a short educational opportunity on this topic and shared that the etiology of the type II MI would not necessarily be CAD but some other insult to the body (sepsis/severe anemia/etc). Therefore, the PDx would not be the MI but would be the disease process that caused the MI (sepsis/anemia/etc).
Thoughts?
Valerie Miller BSN,RN,CCDS
Georgetown Hospital System
Georgetown, SC
I'm not sure, but if you apply that same strategy to the Type 1 MI (which is caused by CAD) it would be coded to the CAD. Type 2 MI is and acute infarction just as Type 1 MI. With that in mind, then, should all MI's be coded to the cause and not the MI itself?
Gail Eaton RN PCCN CDS
Clinical Documentation Specialist
St Joseph Health
2700 Dolbeer, Eureka, Ca, 95501
Office: 707-445-8121 ext 7555
Cell: 707-267-0279
Amber L. Feighner RN MSN
Clinical Documentation Improvement Specialist
Blanchard Valley Hospital
1900 South Main Street
Findlay, Ohio 45840
419-425-5787
The underlying cause of a disease is not consistently used as the principal diagnosis - otherwise, we would use CAD (414.0X) as the underlying cause of an ischemic myocardial infarction. I am sure there are multiple scenarios whereby one may have some sequencing choices from time-to-time.
The circumstances of inpatient admission always govern the selection of principal diagnosis. The principal diagnosis is defined in the Uniform Hospital Discharge Data Set (UHDDS) as "that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care."
B. Two or more interrelated conditions, each potentially meeting the definition for principal diagnosis
When there are two or more interrelated conditions (such as diseases in the same ICD-9-CM chapter or manifestations characteristically associated with a certain disease) potentially meeting the definition of principal diagnosis, either condition may be sequenced first, unless the circumstances of the admission, the therapy provided, the Tabular List, or the Alphabetic Index indicate otherwise.
C. Two or more diagnoses that equally meet the definition for principal diagnosis
In the unusual instance when two or more diagnoses equally meet the criteria for principal diagnosis as determined by the circumstances of admission, diagnostic workup and/or therapy provided, and the Alphabetic Index, Tabular List, or another coding guidelines does not provide sequencing direction, any one of the diagnoses may be sequenced first.
Paul
Paul Evans, RHIA, CCS, CCS-P, CCDS
Manager, Regional Clinical Documentation & Coding Integrity
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell: 415.637.9002
Fax: 415.600.1325
Ofc: 415.600.3739
evanspx@sutterhealth.org
Amber L. Feighner RN MSN CDIS
Clinical Documentation Improvement Specialist
Blanchard Valley Hospital
1900 South Main Street
Findlay, Ohio 45840
419-425-5787
More thoughts on this?
To diagnose type 1 MI, a blood sample must detect a rise or fall (or both) of cardiac biomarker values (preferably cardiac troponin), with at least one value above the 99th percentile. However, an elevated troponin level is not sufficient. At least one of the following criteria must also be met:
Symptoms of ischemia
New ST-T change or LBBB
New pathologic Q wave on ECG
Imaging evidence of new loss of viable myocardium or wall motion
Identification of an intracoronary thrombus by angiography or autopsy
Type 2 myocardial infarction:Due to ischemic imbalance
Type 2 MI is caused by a supply-demand imbalance in myocardial perfusion, resulting in ischemic damage.
This specifically excludes acute coronary thrombosis.
It can result from marked changes in demand or supply (eg, sepsis) or from a combination of acute changes and chronic conditions (eg, tachycardia with baseline coronary artery disease).
Baseline stable coronary artery disease, left ventricular hypertrophy, endothelial dysfunction, coronary artery spasm, coronary embolism, arrhythmias, anemia, respiratory failure, hypotension, and hypertension can all contribute to a supply-demand mismatch sufficient to cause permanent myocardial
damage.
The criteria for diagnosing type 2 MI are the same as for type 1
Therapy should instead be directed
at the underlying supply-demand imbalance
and may include volume resuscitation, blood
pressure support or control, or control of
tachyarrhythmias.
In the long term, treatment to resolve or prevent supply-demand imbalances may also include revascularization or antithrombotic
drugs, but these may be contraindicated in the acute setting.
I have used this query when I see a rise and fall of troponins and vague reference to it:
Please document as a final diagnosis the most appropriate clinical finding supported by your diagnostic efforts.
__ Demand ischemia without Myocardial Infarction
__ Non ST elevation MI (NSTEMI) secondary to known CAD
__ Unstable Angina
__ NSTEMI 2/2 supply demand mismatch also known as Type 2 MI __ Other (please specify) __ Unable to determine
Hope this helps!
Reference:
CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 80 • NUMBER 12 DECEMBER 2013
Since the definition of Type 2 MI is “myocardial infarction secondary to ischemia due to either increased oxygen demand or decreased supply, e.g. coronary artery spasm, coronary embolism, anemia, arrhythmias, hypertension or hypotension,” and the treatment is to treat the underlying condition and hence remove the cardiac insult, then for MOST cases, should it be considered as a SECONDARY DIAGNOSIS (i.e. MCC) ONLY?
Even in the event of a cardiac condition such as rapid atrial fibrillation with significant troponin elevation with type 2 MI, why would you code type 2 MI as PDX (principal diagnosis) if that is not the reason for admission and the treatment course is not to treat AMI/ACS but to treat the rapid atrial fibrillation?
P. Evans, RHIA, CCDS
Paul,
Thank you for responding. So it does matter how the patient presents (as well as focus of treatment), and one cannot make a blanket statement that just because a type 2 MI has been documented it becomes the PDx.
Robert Kopec, MD
Dr. Kopec
That is my understanding. I'd think one would need to consider the 'acuity' of the event causing the type 2 MI as well as the degree and extent of myocardial necrosis and efforts to address the myocardial necrosis. But, I think it plausible to state that if a patient is experiencing a type 2 due to hemorrhagic shock, the shock would probably be the principal dx followed by the type 2: same with sepsis given this would be, IMO, severe sepsis as the sepsis is causing the type 2 MI. This is one of the quibbles I have with SOFA criteria as it is silent in regards to Sepsis causing a type 2 MI. I will say that in my personal observation, the type 2 MI is 'almost always' not the principal diagnosis and certainly I can envision Fib being so severe and persistent, causing the type 2 MI, that the Fib would be the principal. Just my opinion, others may not agree.
Paul Evans, RHIA, CCDS