ICD-10: Coding Snapshot
CHIEF COMPLAINT: Chest pain.
HISTORY OF PRESENT ILLNESS: The patient is a 40-year-old white male who presents with a chief complaint of “chest pain”.
The patient has coronary artery disease of the native arteries. The patient suffered an MI of the left anterior descending artery one week ago and was released two days prior to presentation at this ED. The patient presents today stating that his chest pain started yesterday evening and has been somewhat intermittent. The severity of the pain has progressively increased. He describes the pain as a sharp and heavy pain which radiates to his neck & left arm. He ranks the pain a 7 on a scale of 1-10. He admits some shortness of breath & diaphoresis. He states that he has had nausea and three episodes of vomiting tonight. He denies any fever or chills. He states the pain is somewhat worse with walking and seems to be relieved with rest. There is no change in pain with positioning. He states that he took three nitroglycerin tablets sublingually over the past 1 hour, which he states has partially relieved his pain. The patient ranks his present pain a 4 on a scale of 1-10. The most recent episode of pain has lasted one-hour.
The patient denies any head trauma, recent stroke, abnormal bleeding such as blood in urine or stool or nosebleed.
REVIEW OF SYSTEMS: All other systems reviewed & are negative.
PAST MEDICAL HISTORY: Hypertension, native coronary artery disease
SOCIAL HISTORY: Denies alcohol or drugs. Cigarette dependent – Smokes 2 packs of cigarettes per day. Works as a banker.
FAMILY HISTORY: Negative
MEDICATIONS: Aspirin 81 milligrams QDay. HCTZ 50 mg QDay. Nitroglycerin 1/150 sublingually PRN chest pain.
PHYSICAL EXAM: The patient is a 40-year-old white male.
General: The patient is large but he is otherwise well developed & well nourished. He appears in moderate discomfort but there is no evidence of distress. He is alert, and oriented to person, place, and circumstance. There is no evidence of respiratory distress. The patient ambulates without gait abnormality or difficulty.
HEENT: Normocephalic/atraumatic head. Pupils are 2.5 mm, equal round and react to light bilaterally. Extra-ocular muscles are intact bilaterally. External auditory canals are clear bilaterally. Tympanic membranes are clear and intact bilaterally.
Neck: No JVD. Neck is supple. There is free range of motion & no tenderness, thyromegaly or lymphadenopathy noted.
Pharynx: Clear, no erythema, exudates or tonsillar enlargement.
Chest: No chest wall tenderness to palpation. Lungs: Clear to auscultation bilaterally. Heart: irregularly-irregular rate and rhythm no murmurs gallops or rubs. Normal PMI
Abdomen: Soft, non-distended. No tenderness noted. No CVAT.
Skin: Warm, diaphoretic, mucous membranes moist, normal turgor, no rash noted.
Extremities: No gross visible deformity, free range of motion. No edema or cyanosis. No calf/ thigh tenderness or swelling.
COURSE IN EMERGENCY DEPARTMENT: The patient’s chest pain improved after the sublingual nitroglycerine and completely resolved with the Nitroglycerin Drip at 30 ug/Minute. He tolerated the TPA well. He was transferred to the CCU in a stable condition
10:40 PM Dr. ABC (cardiologist) apprised. He agrees with T PA per 90 minute protocol & IV nitroglycerin drip. He is to come see patient in the emergency department.
10:45 PM risks & benefits of TPA discussed with patient & his family. They agree with administration of TPA and are willing to accept the risks.
10:50 PM TPA started.
11:20 PM Dr. ABC present in emergency department assisting with patient care.
CBC: WBC 14.2, hematocrit 33.5, platelets 316
Chem 7: Na 142, potassium 4.5, chloride 102, CO2 22.6, BUN 15, creatinine 1.2, glucose 186
Serum Troponin I: 2.5
Chest X-ray: Lung fields clear. No cardiomegaly or other acute findings
EKG: Atrial fibrillation with Ventricular rate of 65. Acute inferior ischemic changes noted i.e. ST elevation III & aVF (refer to EKG multimedia).
Cardiac monitor: Sinus rhythm-atrial of fibrillation rate 60s-70s.
Heparin lock X. 2.
Nasal cannula oxygen 3 liters/minute.
Aspirin 5 grains chew & swallow.
Nitroglycerin drip at 30 micrograms/minute.
TPA 90 minute protocol.
Heparin IV 5000 unit bolus followed by 1000 units/hour.
IMPRESSION: Acute Inferior Myocardial Infarction.
PLAN: Patient admitted to Coronary Care Unit under the care of Dr. ABC.
ICD-10-CM Code(s): I22.1 Subsequent ST elevation myocardial infarction of inferior wall
I21.02 ST elevation myocardial infarction of left anterior descending artery
I10 Essential (primary) hypertension
I25.10 Atherosclerotic heart disease of the native coronary artery without angina pectoris
F17.210 Nicotine dependence, cigarettes, uncomplicated
Z79.82 Long-term (current) use of aspirin
Rationale: According to the guidelines, since the patient had a prior myocardial infarction (MI) within the past 28 days, this is a subsequent myocardial infarction. ICD-10-CM has cut down the ICD-9-CM “eight week rule” for timing of myocardial infarctions to 28 days. If a subsequent myocardial infarction is noted (category I22 code), an initial myocardial infarction (category I21 code) must also be reported. In this case, the prior MI is stated to have occurred one week prior in the left anterior descending artery. Since the patient is presenting for care of the new MI, the I22 code for the subsequent MI is reported first. The patient also has coronary artery disease, hypertension, and is nicotine dependent as a two-pack-per-day smoker. These are all important facts to pick up since the patient is presenting with a cardiac-related issue.
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