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

Comments

  • edited May 2016
    Gail,

    Email me your email address and/or phone number. :)

    Dorie Douthit RHIT,CCS
    ddouthit@stmarysathens.org
    Clinical Documentation Specialist/HIM

  • edited May 2016
    Sorry!
    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
  • edited May 2016
    FYI, Attached is the article we used (JAMA 2013) to develop the "elevated troponin" query in conjunction with our cardiologists.
    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

  • edited May 2016
    Awesome. Thank you for sharing.

    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


  • edited May 2016
    Thanks Dorie! We are trying to get to that point.
    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

  • One issue to keep in mind related to documentation (and coding) of Type II MI -- this will likely fall into your core measures and your MI quality data base. Has the possibility of negatively affecting those quality measures if the relevant clinical measures/goals are not met.

    Don

  • edited May 2016
    Thank you for bringing up this point. We have alerted our core measure people and will be keeping track to see if there is any fall out. Thanks to all and gods bless this site and all who contribute! Happy Friday!

    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

  • Hi Gail,

    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
  • edited May 2016
    Hi Valerie,

    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
  • edited May 2016
    I agree with Gail. In regards to Core Measures if the patient still had an MI regardless of the cause it would be included in the core measure data right? We were experiencing this "Type II MI" dilemma as well. The MDs were charting "demand mismatch type II infarct" and never really were calling it an MI. According to Up to Date type II MI is still and MI and is usually treated (even if minimally)...so education was provided back to those that were documenting this and the effect that it could have on the core measures and now the physicians document MI secondary to.....whatever the cause may be. A little coding education was provided as well in regards to the definition of secondary diagnoses.....haven't had much of an issue since that time. I think this can be a very grey area for both practitioners and coding. Conversation with all parties helped us a lot.

    Amber L. Feighner RN MSN
    Clinical Documentation Improvement Specialist
    Blanchard Valley Hospital
    1900 South Main Street
    Findlay, Ohio 45840
    419-425-5787

  • I am very confused now.
  • If the acute myocardial infarction is present on admission, it should be considered strongly for consideration as the principal diagnosis. There could be exceptions, one example being something as severe as Sepsis causing the AMI.

    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

  • edited May 2016
    Thanks for your input, Paul.  I will share this with our Chief of Medicine and also our Director of Outcomes Measurement.   





  • edited May 2016
    We use the MI diagnosis as our principal diagnosis. The physicians are encouraged to document any other diagnosis with a relationship to the MI if known.

    Amber L. Feighner RN MSN CDIS
    Clinical Documentation Improvement Specialist
    Blanchard Valley Hospital
    1900 South Main Street
    Findlay, Ohio 45840
    419-425-5787

  • I query for the "I" in the MI, such as is it: Myocardial Infarction or is it Myocardial Ischemia. If infarction then move forward with is it: STEMI or NSTEMI.
    More thoughts on this?




  • Type 1: Spontaneous myocardial infarction

    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
  • Thank you!


  • 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?

  • Depends upon the circumstances of admission - focus of treatment.  Would a patient with a Type 2 MI not have any diagnostic efforts or treatment directed to the MI?  But, definitely agree there are many scenarios in which the type 2 would be sequenced as a secondary, such as if a septic patient experiences a type 2 MI due to sepsis.

    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

  • Although, in retrospective,  I have only used a type 2 MI as a secondary code in practice.  Lending support to your statement, Dr. Kopec.    Not sure if others may have a different point of view?
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