Cardiology Coding Alert

Avoid using 'unspecified' by investigating chart Rather than falling back on an unspecified code for a myocardial infarction (MI) diagnosis when you don't have enough information, remind your cardiologist to note when the MI happened and where the damage occurred.
 
When the physician documents these two aspects of the MI, you can easily choose the correct diagnosis code, including the required fourth and fifth digits. Choose 410 Series for Acute MI A patient has an MI (commonly known as a heart attack). Your cardiologist sees the patient in the hospital, the office or another setting during the eight weeks immediately following the MI. You should code the diagnosis using the 410 series (Acute myocardial infarction), with required fourth and fifth digits.
 
"When coding an MI, it's always nice to have information on the exact location and episode of care, but we don't always get it," says Joanna Anderson, CPC, billing manager and coder at Peninsula Cardiology Associates in Salisbury, Md.
 
Don't fall for "unspecified": You may look to 410.90 (Acute myocardial infarction; unspecified site and episode of care) if you lack necessary documentation, but don't fall into that trap.
 
"For cardiology specialists, my suggestion is that you never use the unspecified code," says Nancy Emerick, coder at North Ohio Heart Center in Avon, Ohio. "A cardiologist should be able to determine from a combination of diagnostic testing the specific location of an MI. And you should talk with your physician regarding the importance of both the location and the episode of the MI."
 
What you need to know: You need to figure out where the MI occurred in order to pick the correct fourth digit, ranging from 0 (Of anterolateral wall) to 9 (Unspecified site). You also have to decide on a fifth digit. Your options are 0 (Episode of care unspecified), 1 (Initial episode of care), or 2 (Subsequent episode of care). Find Out Where for 'MI' If the cardiologist documents only "MI," you may have to don a Sherlock Holmes hat and do some investigating.
 
One tactic is to check for an emergency department note. "If I had at least an ED note, I could look at the EKG findings (such as elevation in the inferior and lateral leads) and query either the attending physician who saw the patient or a cardiologist to see if the findings in the ED note are consistent with, for example, an inferiolateral MI," says Sharon Threadgill, medical record technician and inpatient coder for the Department of Veteran Affairs Medical Center in Salem, Va.
 
You may also want to check for a cardiac catheterization, coronary angioplasty, echocardiography, or even a nuclear perfusion scan report in the chart, but make sure you confirm the MI location with [...]