lasonya
New
I would love to get someone's thoughts on the following: I am currently auditing HCC coding and the only documentation for MI is the word MI(selected in a current conditions list) and a place for the clinician to add the date. In order to code an MI the coder needs to know the date (of course),if it is STEMI or NSTEMI, and site. If site is given but no info on whether it’s STEMI or NSTEMI, we can code to STEMI by site. In my case I don’t have the site nor STEMI vs. NSTEMI. Do you interpret STEMI as being the default and the site would be unspecified so the code would be I21.3 with the limited documentation? The coders have been coding it as I25.2 for old MI becauce the clincians provide outpatient services in the patient's home and not in an inpatient setting and this info usually comes from the patient. The clinician would never know if it's STEMI or NSTEMI nor will they know the site. Thoughts form someone with HCC coding experience.