Cardiology Coding Alert

Question: The physician documented only "MI" for the patient's diagnosis. Can I report anything more specific than that?


Pennsylvania Subscriber

 
Answer: You may be able to report a more specific diagnosis if you investigate the documentation more closely and query the doctor. 

One tactic is to check for an emergency department (ED) note. If you have an ED note, you can 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 whether the ED findings are consistent with certain conditions -- for example, an inferolateral myocardial infarction (MI).

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 the attending physician.

However, if the patient presents with symptoms and positive test results, and the physician only documents "MI" (without stating the site or episode of care), you can use 410.90 (Acute myocardial infarction; unspecified site; episode of care unspecified) -- only if this necessary documentation is truly unavailable. But you shouldn't make that a habit.

You Be the Coder and Reader Questions were prepared with the assistance of Jim Collins, ACS-CA, CHCC, CPC, CEO of the Cardiology Coalition and compliance manager for several cardiology groups around the country; and reviewed by Jerome Williams Jr., MD, FACC, a cardiologist with Mid Carolina Cardiology in Charlotte, N.C.