NSTEMI type 2

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in CDI Talk Archive
We are doing a chart analysis of our NSTEMI as a secondary diagnosis charts. Our docs clasify NSTEMI as type 1 or type 2. Does anyone else see these classifications by their docs? We are concerned that we have a higher rate of NSTEMI type 2 as a secondary diagnosis compared to other hospitals in our area and that this will be a focus of RAC. Just wondering if anyone else has seen this. Also, if anyone knows the criteria for diagnosis for NSTEMI type 2. Thanks.

Comments

  • robert.hodges2robert.hodges2
    edited April 2016
    I've not heard of that classification before. What is their reference? I know for coding it's for the initial episode of care vs. subsequent episodes of care.

    Robert

    Robert S. Hodges, BSN, MSN, RN
    Clinical Documentation Improvement Specialist
    Aleda E. Lutz VAMC
    Mail Code 136
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  • dholowczakdholowczak
    edited April 2016
    I found this website helpful for distinguishing MI types

    www.escardio.org/guidelines

    Deanna Holowczak, BSN, RN
    Clinical Documentation Specialist
    St. John's Riverside Hospital
    914-964-4580
    dholowczak@riversidehealth.org

  • dallend@einstein.edudallend@einstein.edu
    edited April 2016
    At this time we do not query to clarify the type of NSTEMI. Our physicians do not document this information on their own. I review charts on the cardiac floor and I have never seen our physicians document to that level of detail.

  • kari.eskenskari.eskens
    edited April 2016
    We do not see MI specified to that level either. The current set of diagnosis codes does not specify NSTEMI as type 1 or 2. All NSTEMI are the same in the data world. There wouldn't be anything in the coded data to alert RAC that you may be doing something differently that the norm. I personally wouldn't be concerned of this being a RAC focus area.

    Kari L. Eskens, RHIA
    BryanLGH Medical Center
    Coding & Clinical Documentation Manager

  • paflor2paflor2
    edited April 2016
    We see this documentation consistently from physicians at our facility, particularly if the MI is a Type 2. We have been seeing this information in charts for almost a year now.

    I believe the new guidelines include MIs that are listed as Types 1 to 5.

    There is information available from the ACC (American College of Cardiology) and there is an easy to read presentation at this link:
    http://www.escardio.org/guidelines-surveys/esc-guidelines/GuidelinesDocuments/guidelines-universal-MI-slides.pdf


    I do not believe it makes any difference what type of MI the patient has at this time for coding purposes, only whether it is acute or not. The ICD-9 classification has not yet "caught up" with current clinical practice.

    Hope this helps.


  • kmaritankmaritan
    edited April 2016
    I agree. To put it very plainly, this is not an issue for anything but your own hospital stats. The only codes for NSTEMI are 410.70 (unspecified), 410.71 (initial episode of care) and 410.72 (subsequent episode of care). There is no ICD-9 code for specificity for Type 1 or Type 2 NSTEMI. There may be in ICD-10 but not now. Therefore, there is no impact to severity of illness, risk of mortality or reimbursement for these "types."

    Karen Maritano, RN
    Documentation Specialist
    Care Management
    Legacy Health
    phone 503-413-7154
    pager 503-983-0683

  • sbeattysbeatty
    edited April 2016
    I've found the reference that I believe your cardiologists are using.
    It's aan article on "Definition of Myocardial Infarction" task force
    work. I've got it downloaded as a pdf, so send me your email address and
    I will send it to you. OR

    Google this phrase:
    "Universal Definition of Myocardial Infarction".

    One of the first hits you get is for circaha...... I forget the rest of
    the URL, but it will open to the magazine Circulation. Clcik on the
    download this article as PDF. Page 2637 has the table with classes of
    MIs.

    Today I've learned something as well. Thanks!

    Is there anything else I can do for you?
    Clinical Quality Management would like your feedback on our ability to
    meet your needs. Please complete a satisfaction survey for our
    department.

    Sandy Beatty, RN, BSN, C-CDI
    Clinical Documentation Specialist
    Columbus Regional Hospital
    Columbus, IN
    (812) 376-5652
    sbeatty@crh.org

    "The most important thing in communication is to hear what isn't being
    said." Peter F. Drucker

  • sbeattysbeatty
    edited April 2016
    The URL for the MI definitions from the 10/2007 issue of Circulation:
    http://circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.107.187397



    Is there anything else I can do for you?
    Clinical Quality Management would like your feedback on our ability to
    meet your needs. Please complete a satisfaction survey for our
    department.

    Sandy Beatty, RN, BSN, C-CDI
    Clinical Documentation Specialist
    Columbus Regional Hospital
    Columbus, IN
    (812) 376-5652
    sbeatty@crh.org

    "The most important thing in communication is to hear what isn't being
    said." Peter F. Drucker

  • Unknown
    edited April 2016
    It has to do with whether the NSTEMI is from CAD vs another cause such as demand ischemia. If it is classified as NSTEMI type 2 our coders are using it as a secondary diagnosis never a principal.


    Gina Spatafore, RN
    Clinical Documentation Integrity Specialist
    Waterbury Hospital
    203 573 7647

  • dogdog
    As far as your coders "never coding as principal," in the absence of a coding clinic, aren't they still supposed to follow the sequencing rules for selecting a principal diagnosis? If the reason after careful study for the admission is the NSTEMI, then doggone it, it's the NSTEMI.

    JMNSHO,

    Renee

    Linda Renee Brown, RN, CCRN, CCDS
    Clinical Documentation Specialist
    Arizona Heart Hospital
  • cbarnescbarnes
    edited April 2016
    AGREED !!

  • Unknown
    edited April 2016
    Thank you for the references and information everyone. This is helpful.
    We are going to do a literature review for evidenced based back up.

    Gina Spatafore, RN
    Clinical Documentation Integrity Specialist
    Waterbury Hospital
    203 573 7647

  • dallend@einstein.edudallend@einstein.edu
    edited April 2016
    I agree!!

  • darlenesaddressdarlenesaddress
    I have not seen that classification used anywhere. MI's are classified as type I for a STEMI and type II for a NSTEMI in general, but even with research I could not find reference to NSTEMI 1 and 2. Are you perhaps doing a research study? It would be interesting if you could find out what criteria is being used to separate the two NSTEMI's and share it with us.
    Thanks!
    Darlene Shelffo
    Tampa General Hospital
    Tampa, Florida
  • evanspx@sutterhealth.orgevanspx@sutterhealth.org
    edited April 2016
    A 'type 2 NSTEMI" will be coded as an AMI....your approach asking that one distinguish ACS from all forms of AMI is the proper approach, IMO>



    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

    evanspx@sutterhealth.org



  • jlightfoot@marshallmedical.orgjlightfoot@marshallmedical.org
    edited April 2016
    We've had similar discussions with our core measures people and our physicians; there are also several good articles from Dr Gold or Kennedy out there about diagnosing and sequencing of a demand mediated MI (NSTEMI or type 2 MI). If I can find them I will post later today.

    As a rule, demand mediated MI's do not meet criteria for the Pdx; the underlying cause/condition should be the Pdx. Many of our demand mediated MI's have a non cardiac cause such as sepsis or acute respiratory failure. If you have a cardiac Pdx, say Afib, with the NSTEMI as a secondary diagnosis, the DRG will default to 280-285 (MI) but since core measures are based on the Pdx, not the DRG, these pt's do not fail because of lack of appropriate treatment.

    The physicians also have the option of including in their documentation why certain therapies were not ordered to avoid failure of core measures (contraindicated or inappropriate for this pt, etc.)

    Good luck!

    Our biggest dilemma on this topic has been getting agreement amongst the physicians about demand mediated injury (CC) and demand mediated MI (MCC); most use these terms interchangeably, but a few feel they represent different conditions. We're working on organizational guidelines and definitions for demand mediated NSREMI if anyone has any feedback, it would be greatly appreciated.


    Jillian Lightfoot RN
    Clinical Documentation Team
    Marshall Medical Center
    Placerville, CA 95667
    (530) 626-2770 Ext. 6203
    jlightfoot@marshallmedica.org






  • julie.cruz-sjejulie.cruz-sje
    edited April 2016
    Hello all, this is a flow sheet that was developed in collaboration with our Cardiology Team at our facility. Our hospitalists use this as reference if we are querying for a Type 2 MI since it is fully endorsed by our cardiologists. A type 2 MI (demand ischemia) can still be picked up as an MCC (secondary dx) and not as a PDX.
    I have also attached the query we use specifically for this Dx if there is a troponin elevation.

    Hope this helps some of you who like visual aids such as us!

    Julie Cruz RN, CDS and Gail Eaton RN, CDS

    Clinical Documentation Specialist
    St. Joseph Health
    2700 Dolbeer St
    Eureka, CA 95501
    wk: 707-445-8121 ext. 7550
    cell: 707-267-0973

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