myocardial injury vs demand ischemia vs Type 2 MI

How are people dealing with the new Myocardial injury code it seems to muddy the water further.

Type 2 MI is due to a supply demand mismatch, not a coronary occlusion.

From many conversations with other CDI, providers and cardiologist, i felt pretty confident in understanding and how to phrase the question to providers to make their decision. BECAUSE THEY DO NOT ALL AGREE, BUT we present the information and they decide.

  1. We confirm 99th percentile... so that was half of the needed criteria.
  2. meet one of 5 :

Demand ischemia was less than 99th percentile, OR not meeting any of the 5 criteria.

EKG changes, ECHOS, and Angiography are concrete, but what is a symptom of myocardial ischemia? only Chest pain? what about Silent MI?

This is the least concrete and dependent on the provider's judgement.

Per Mayo:


Some people who have myocardial ischemia don't have any signs or symptoms (silent ischemia).

When they do occur, the most common is chest pressure or pain, typically on the left side of the body (angina pectoris). Other signs and symptoms — which might be experienced more commonly by women, older people and people with diabetes — include:

  • Neck or jaw pain
  • Shoulder or arm pain
  • A fast heartbeat
  • Shortness of breath when you are physically active
  • Nausea and vomiting
  • Sweating
  • Fatigue

So when would Type 2 MI be appropriate? When Myocardial Injury? when demand ischemia?

Also the latest coding guidelines don't mention it.


  • Adding an article that helps, in the way I see it.

    I think I have seen some education on the Non-ischemic myocardial injury that could be confusing, and make people think they cannot have a type 2 Mi without EKG,ECHO, angiography.

    I think the code is meant to represent, elevation in troponin without a S/s of ischemia, which may need to be queried.

  • We are struggling with this as well. Our providers are stuck on the idea that if there are elevated troponins then it must be either a T2MI or demand ischemia. There is very little education available out there to help educate the CDI and doctors on the differences between the three diagnoses. Our hospitalists want to refer to our Cardiologist but our Cardiologists are often the ones stating T2MI and demand ischemia when there are no s/s of ischemia present.

  • When writing a query for the conflicting documentation or clinical significance of the Troponin levels monitored remember to provide signal not noise

    Provide the following information:

    >Presenting symptoms

    >12 lead EKG reading from providers: (ER MD might interpret differently from consultant or attending)

    >Time and result of Troponins 

    >Echo results focusing on wall motion only if performed 

    >Nuclear scan from stress test if performed 

    >Coronary Angio results if performed 

    >LV Gram wall motion results if performed 

    Provide documented diagnosis regarding the “ elevated troponins” from providers on record. 

    *Remember to only offer the applicable choices based on the evidence in the record or conflicting documentation in the record.

    Based on your interpretation of the clinical findings including the troponin trend can you please choose the clarification below as appropriate?

    __ Myocardial infarction ruled out, elevated troponins due to non-ischemic myocardial injury 2/2_____ 

    __ Myocardial infarction ruled out, not able to further clarify the elevated troponins 

    __ Demand ischemia secondary to _________  

    __ Type 2 MI 2/2 __________________                                

    __ NSTEMI                                                      

    __ NSTEMI that evolved into a STEMI                                                   

    __ STEMI                                                                   

    Other Response ______________                                                   

    defer to ___________ 

  • We just recently sent a physician education regarding this topic. What we have found is with the education there is still a lot of confusion among our doctors. We have also found that since we have sent out the education that we have had more queries regarding these diagnosis due to trying to have appropriate coding. Attached is our physician education in case any of you fill it will help in your practice.

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