Internal Medicine Coding Alert

Coders may occasionally see documentation of "Dressler's syndrome" in the chart. This is a complication that develops days or weeks after an MI and includes symptoms such as fever, chest pain and evidence of pericarditis. Use 411.0 (Postmyocardial infarction syndrome) for this complication.

Most MI patients have underlying coronary artery disease, so internists will often use 414.00 (Coronary atherosclerosis of unspecified type of vessel, native or graft) or 414.01 ( of native coronary artery) as a primary or secondary diagnosis with the MI patient. Internists don't normally use the other fifth digits in this series because these address plaque build-up from atherosclerosis on bypass grafts and transplants.