Coding sequence for for in-stent restenosis of a cardiac stent

Per DCS - which showed significant in-stent restenoses of proximal RCA stent, which was treated with Synergy
drug-eluding stent.

The coder are a bit confused as to sequencing...
I121.A9 other type of MI and then the book states also code complication...which would be the T82.857 codes. So the question the complication code sequenced first then the MI code or the other way around? We have been told to usually code the complications first if it is due to a I am a bit lost...Help!


  • The complication code is sequenced first.
  • There is a new code for MI due to in-stent restenosis, as below 


    Issue:Fourth Quarter
    Title: Types of Acute Myocardial Infarction, p 12

    Volume 4         Fourth Quarter

    Number 4         2017, Page 12




    Summary explanations of the Fiscal Year 2018 (FY 2018) ICD-10-CM changes effective October 1, 2017 are provided below. Addenda changes demonstrating the specific revisions to the code titles or instructional notes are not included in the explanations below. The official ICD-10-CM addenda has been posted on the Centers for Disease Control and Prevention (CDC) National Center for Health Statistics website at


    There are 360 new ICD-10-CM codes implemented on October 1, 2017. In addition, 141 codes have been deleted and 226 code titles revised.


    Types of Acute Myocardial Infarction


    The following changes have been made at category I21, Acute myocardial infarction, to align with a new clinical classification of myocardial infarctions:


    • New inclusion terms added at codes I21.0 to I21.4, to clarify that these codes refer to type 1 myocardial infarctions

    • New code created for unspecified acute myocardial infarction (I21.9)

    • New subcategory (I21.A) added for other types of myocardial infarctions with code I21.A1, Myocardial infarction type 2, and code I21.A9, Other myocardial infarction type


    Codes from category I22, Subsequent ST elevation (STEMI) and non- ST elevation (NSTEMI) myocardial infarction, should not be assigned for subsequent myocardial infarctions other than type 1 or unspecified. Subsequent type 2, 4 or 5 myocardial infarctions are coded by type rather than using codes from category I22. For example, for subsequent type 2 acute myocardial infarctions, assign code I21.A1; for subsequent type 4 or type 5 acute myocardial infarction, assign code I21.A9. There is no subsequent type 3 myocardial infarction, as type 3 refers to myocardial infarction resulting in death when biomarker values are unavailable.


    In addition, new Official Guidelines for Coding and Reporting have been created to clarify the usage of the new codes.


    A global task force, which included the European Society of Cardiology, the American College of Cardiology, the American Heart Association and the World Heart Federation (WHF), developed a consensus clinical classification of myocardial infarctions. Referred to as the “Third Universal Definition of Myocardial Infarction,” it classifies acute myocardial infarction into the following subtypes:


    • Type 1: Spontaneous myocardial infarction due to a primary coronary event like plaque rupture.

    • Type 2: Myocardial infarction secondary to an ischemic imbalance as in coronary vasospasm, anemia or hypotension.

    • Type 3: Myocardial infarction resulting in death when biomarker values are unavailable

    • Type 4a: Myocardial infarction related to percutaneous coronary intervention (PCI)

    Type 4b: Myocardial infarction related to stent thrombosis

    • Type 4c: Myocardial infarction due to restenosis ≥50% after an initially successful PCI

    • Type 5: Myocardial infarction related to coronary artery bypass grafting (CABG)

    Year: 2016
    Issue: Fourth Quarter
    Title: I10 Complications of Cardiac & Vascular Prosthetic Devices, Implants, p 70


    NUMBER 4       2016, Page 70


    Complications of Cardiac and Vascular Prosthetic Devices, Implants and Grafts


    Two new codes have been created to uniquely differentiate stenosis of coronary artery stent (T82.855) from stenosis of peripheral vascular stent (T82.856). These codes include in-stent stenosis as well as restenosis. Codes T82.857 and T82.858 have been revised accordingly to identify stenosis of “other cardiac prosthetic devices, implants and grafts” (T82.857) and “other vascular prosthetic devices, implants and grafts” (T82.858).


    In addition, the code titles in sub-subcategories T82.81, T82.82, T82.83, T82.84 and T82.86 have been changed from “of” to “due to” as shown in the example below:


    Revise from T82.817 Embolism of cardiac prosthetic devices, implants and grafts

    Revise to T82.817 Embolism due to cardiac prosthetic devices, implants and grafts



    Coding advice or code assignments contained in this issue effective with discharges October 1, 2016.

  • Key Thought:   Is the artery with the in-stent stenosis the culprit lesion causing the new acute infarct?  This must be the case in order to consider using the complication code as the PDX.

    There is a specific code for both the complication as well as the type of MI and a 'code also' annotation.

    A “code also” note alerts the coder that more than one code may be required to fully describe the condition. The sequencing depends on the circumstances of the encounter. Factors that may determine sequencing include severity and reason for the encounter.

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