AMI sequencing

I'm in need of a reference for AMI sequencing. I was told when I began as a CDIS almost 5 years ago that when a patient is admitted with many diagnosis and AMI was one of the diagnoses, AMI is to always be the principle diagnosis. I have looked in coding clinic and coding guidelines but am not having success in fidging the reference. I'm probably overlooking it.

Do you know where I might find the reference.

Comments

  • edited May 2016
    Great question. Last week I reviewed a case where I took it to the AMI and had the documentation for CHF as the MCC. The coder used the CHF as the PDX BUT it still coded to the AMI DRG and of course, no MCC. This really confused me. It was reviewed by an auditor who happened to be at our hospital who said that is legitimate. It was determined that it was the CHF driving the admission even though AMI was POA. Still not sure I completely agree with this rationale...
  • It's not that the MI must be PDX, it's just that it trumps other dx when sequencing. The caveat on that is that the alternate PDX must be in the circulatory group. MI, like any other dx, must meet the definition of PDX. If they come in with acute diverticulitis and an acute MI, you can choose either one if they both meet the definition of PDX. But if they come in with PVD and an acute MI, you still have to decide which one is PDX--it's just that the DRG will default to the 280-282 grouping...unless they go for surgery. So if they come in with acute systolic HF and an MI, if you pick the SHF as pdx, you lose the MCC because you are "better off" moving into the MI group--SHF wasn't your MCC, it was the PDX. If the MI is truly the pdx, then you can take the SHF as an MCC to go to DRG 280. Confusing, yes. Try running different scenarios through your encoder, if you use one.

    Renee


    Linda Renee Brown, RN, CCRN, CCDS
    Certified Clinical Documentation Specialist
    Banner Good Samaritan Medical Center
  • edited May 2016
    The reference is in the DRG manual on page 159. If MI is the principal or secondary diagnosis with any CIRCULATORY principal diagnosis, it will group to the MI DRG's.

    Cathy Seluke, RN
    Care Management
    Phone: (207) 872-1796
    Pager: (207) 823-0717
  • edited May 2016
    What and or whose DRG manual? It is not in DRG Expert page 159
  • A "Smart Tip" comes to my mind when looking up 410.91 (MI). It says, "When it is the case that after study the acute myocarial infarction meets the definition of principal diagnosis and coronary atherosclerosis is also documented, sequence the acute myocardial infarction as the principal diagnosis with the additional code of coronary artery atherosclerosis. See article on pages 69-72 CC 4 Q 2005 for information. Source: CC4Q 2005".
  • Just to further clarify:

    Whenever a patient is admitted with a PDx that indexes to MDC 5, Circulatory and an AMI (initial episode of care) is diagnosed at any time during the same encounter (admission), the PDx will be 1) that condition after study to have occasioned the admission), BUT the AMI will determine the final DRG.

    Example:

    PDx: DVT (or arrhythmia, CHF, endocarditis, for example)- (POA)
    SDx: AMI (not POA)
    DRG: 282 AMI w/out CC/MCC

    If the AMI gets the "power" to drive/determine the DRG it can't also act as the MCC, which it ordinarily would, given it's MCC designation

    But - consider the following:

    PDx: Atrial fib (for sure, no evidence of MI at admission)
    SDx: ESRD
    SDX: AMI

    DRG: 280 AMI w/MCC

    So if the MI occurs or is diagnosed after admission (and clearly no MI symptoms on admit) then it will not become the PDx and take the place of the original PDx. Only the final DRG will change.

    Further example:

    PDx: Stroke (POA)
    SDx: AMI (not POA)
    DRG: 064 Acute cerebral infarction w/MCC

    In summary, this rule only applies to any other PDx in Circulatory.
  • edited May 2016
    Because the CDS I precepted was more confused than helped by my verbal explanation of the MI sequencing guidelines, I decided to write a short article on the subject. Would welcome comment.

    Renee


    Linda Renee Brown, RN, CCRN, CCDS
    Certified Clinical Documentation Specialist
    Banner Good Samaritan Medical Center
  • edited May 2016
    Renee - really, really well done - thanks a million for sharing.
  • edited May 2016
    I agree, love-love-love it.
  • Excellent article with GREAT explanation
  • edited May 2016
    If you run those two diagnoses through the encoder you get DRG 871 (with MCC)



    Charlene
  • If documented circumstances of admission, w/u and therapy provide
    facility with a 'sequencing choice', either may be used as the PDX with
    result either will be an MCC.

    (Perhaps you are thinking of some other rule pertaining to SIRS/Sepsis
    sequencing, for instance, if pt with an infection, such as PNA, is
    admitted with SIRS due PNA, then SIRS/Sepsis MUST be the PDX?)

    However, if pt with 'significant' non-infectious condition, such as CVA
    or AMI is also septic, then may be compliant coding and sequencing
    choices...it depends.

    Paul Evans, RHIA, CCS, CCS-P
    Supervisor, Clinical Documentation Integrity, Quality Department
    California Pacific Medical Center
    2351 Clay #243
    San Francisco, CA 94115
    Cell: 415.637.9002
    Fax: 415.600.1325
    Ofc: 415.600.3739

  • According to coding guidelines, whenever sepsis meets the criteria as principal dx it is always coded first. If sepsisand MI both meet the criteria for principal dx, sepsis still would be principal. The only time sepsis is not a principaldx is if it was not present on admission.
    Thank you,

    Angie Mckee, RHIT, CCDS, CCS, CCS-P
    Clinical Documentation Specialist
    Performance Improvement
    University Health Care System
    Augusta, Ga. 30901
    706-774-7836
  • Respectfully disagree that the coding guidelines state that "whenever
    sepsis meets the criteria as PDX it MUST always be coded first". This
    is not the case - cite the rule, please. There is no rule state Sepsis
    'must' be the PDX when a patient is also admitted with another condition
    that may be unrelated to infection/sepsis, such as severe MI with
    Cardiogenic shock, for instance, or a devastating hemorrhage of the
    brain with severe consequences.

    Guidelines state:

    Sepsis/SIRS with Localized Infection

    "If the reason for admission is both sepsis, severe sepsis, or SIRS and
    a localized infection, such as pneumonia or cellulitis, a code for the
    systemic infection (038.xx, 112.5, etc) should be assigned first, then
    code 995.91 or 995.92, followed by the code for the localized infection.
    If the patient is admitted with a localized infection, such as
    pneumonia, and sepsis/SIRS doesn't develop until after admission, see
    guideline I.C.1.b.2.b)."

    END OF QUOTE:

    These guidelines apply if/when pt admitted solely for infection, such as
    PNA, with SIRS/Sepsis.

    However, if pt is admitted with Sepsis due to infection as well as ICH
    with brain death due to hernia, in a coma and other documentation of a
    catastrophic Brain event NOT due to Sepsis, a coding choice is
    feasible. Admittedly, not very common, but we have had multiple admits
    here for 'severe MI with cardiogenic shock, Sepsis due to PNA, and
    severe ICH with brain edema.

    REFERENCE:

    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 Evans, RHIA, CCS, CCS-P
    Supervisor, Clinical Documentation Integrity, Quality Department
    California Pacific Medical Center
    2351 Clay #243
    San Francisco, CA 94115
    Cell: 415.637.9002
    Fax: 415.600.1325
    Ofc: 415.600.3739
  • edited May 2016
    Paul,
    I agree with your thinking. I was going to post the same, but you did it much better than I.

    Kari L. Eskens, RHIA
    BryanLGH Medical Center
    Coding & Clinical Documentation Manager
  • Thank you, Kari. I work at a tertiary referral center with a high
    patient level of morbidity and coding complexity. We have patients
    admitted fitting the scenario below on a regular basis - unfortunately
    and as you can imagine, I can't recall that any of them have survived.


    Paul Evans, RHIA, CCS, CCS-P
    Supervisor, Clinical Documentation Integrity, Quality Department
    California Pacific Medical Center
    2351 Clay #243
    San Francisco, CA 94115
    Cell: 415.637.9002
    Fax: 415.600.1325
    Ofc: 415.600.3739
  • The original question was regarding Sepsis vs NSTEMI, without anything to include catastrophic illness. NSTEMI was apparently simple (because there is no suggestion of anything other than simple) and would not support principal diagnosis assignment over sepsis in any case. After study, the sepsis would be more resource intensive than simpleNSTEMI. Of course, in the event of catastrophic illness with sepsis the scenario is different than sepsis vs NSTEMI.
    Thank you,

    Angie Mckee, RHIT, CCDS, CCS, CCS-P
    Clinical Documentation Specialist
    Performance Improvement
    University Health Care System
    Augusta, Ga. 30901
    706-774-7836
  • Understood - I was responding to the statement made that 'whenever
    sepsis meets the criteria as PD it is ALWAYS coded first' - there are
    exceptions and sequencing can be complicated and sophisticated -
    selection of PDX can be 'hard' and requires in-depth analysis. I took
    care to explain my rationale carefully.

    Paul Evans, RHIA, CCS, CCS-P
    Supervisor, Clinical Documentation Integrity, Quality Department
    California Pacific Medical Center
    2351 Clay #243
    San Francisco, CA 94115
    Cell: 415.637.9002
    Fax: 415.600.1325
    Ofc: 415.600.3739
  • edited May 2016
    I refer to Renee's WONDERFUL article frequently and am very comfortable going to the AMI DRG following Renee's suggestions - another "gift" from CDI Talk! I know the encoder knows this rule too. What I can't find is a reference which supports sequencing AMI within the circulatory MDC. I looked at the coding guidelines, Faye Brown and coding clinic.

    The closest I found is in DRG Expert - DRG 280 - above the list of ICD-9 codes, "Principal or Secondary Diagnosis".

    Renee, if you are out there, what reference did you use to get so smart??? Or if anyone else has a suggestion would sure appreciate it.

    Thank you,


    Linnea Thennes, RN, BS, CCDS
    Supervisor, Clinical Documentation Improvement
    Centegra Health System
    815. 759-8193
    lthennes@centegra.com

    PS: I believe you can find Renee's article on the ACDIS website if interested.
  • STEMI with PCI DES (drug eluting stent).

    MS-DRG should be 247 (w/o MCC), correct?

    The procedure should trump the AMI DRG 282 (w/o CC or MCC); just want to confirm.

    Robert Kopec, MD, CPE, CCDS

    robert.kopec@baycare.org

Sign In or Register to comment.