Get to the Heart of Chest Pain Coding
Put your diagnosis coding skills to the test with this ED patient encounter.
CC: Chest pain
HPI: The patient is a 40-year-old white male with coronary artery disease of the native arteries who presents with chest pain that started yesterday evening. The patient suffered a myocardial infarction (MI) of the left anterior descending artery one week ago and was released two days prior to presentation at this emergency department (ED).
The patient states that his chest pain started yesterday evening and has been intermittent. The pain is worse with walking and seems to be relieved with rest. There is no change in the pain with positioning. The severity of the pain has progressively increased; at its worst, he ranks it an eight on a scale of 1-10. He describes the pain as a sharp and heavy pain that radiates to his neck and left arm. The patient admits some shortness of breath and diaphoresis and states that he has had nausea and two episodes of vomiting tonight. He denies fever, chills. No history of head trauma, recent stroke, or abnormal bleeding.
He took three nitroglycerin tablets sublingually over the past one hour, which he states has partially relieved his pain. His current pain level is a four; the most recent episode of pain lasted one hour.
ROS: As per HPI; otherwise negative.
PMH/PSH: Hypertension, coronary artery disease, MI one week ago.
MEDS/ALLERGIES: Aspirin 81 mg daily, HCTZ 50 mg daily, nitroglycerin 1/150 sublingually PRN chest pain. NKDA.
SOCIAL Hx: Denies alcohol or drugs. Cigarette dependent – smokes two packs of cigarettes per day. Works as a banker.
FAMILY Hx: Negative.
PHYSICAL EXAM: Gen: The patient appears in moderate discomfort but there is no evidence of distress. AAO x 3. The patient ambulates without difficulty; no gait abnormality.
HEENT: Normocephalic/atraumatic. Pupils are 2.5 mm, equal, round, and react to light bilaterally. Extraocular muscles are intact. External auditory canals are clear. TMs are clear and intact. Pharynx is clear; no erythema, exudates, or tonsillar enlargement.
Neck: Supple; no JVD. There is free range of motion and no tenderness, thyromegaly, or lymphadenopathy noted.
Chest: No chest wall tenderness. Cardio: irregularly-irregular rate and rhythm; no murmurs, gallops, or rubs. Normal PMI. Pulm: CTAB; breath sounds equal, breathing comfortably. No evidence of respiratory distress.
Abd: Soft, NT/ND.
Skin: Warm, diaphoretic, normal turgor, no rash noted.
Extremities: No gross visible deformity, good ROM. No edema, erythema, or cyanosis. No calf/ thigh tenderness or swelling.
COURSE IN ED: The patient’s chest pain improved after sublingual nitroglycerine and completely resolved with a nitroglycerin drip at 30 ug/min. He tolerated the TPA well. He was transferred to the coronary care unit (CCU) in stable condition.
10:40 pm: Cardiologist, Dr. ABC, apprised. She agrees with TPA per 90-minute protocol and IV nitroglycerin drip. She is to come to see patient in the ED.
10:45 pm: Risks and benefits of TPA discussed with patient and 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 ED assisting with patient care.
CBC: WBC 14.2, hematocrit 33.5, platelets 316; Chem 7: Na 142, K 4.5, Cl 102, CO2 22.6, BUN 15, creatinine 1.2, glucose 186; serum Troponin I: 2.5.
Chest X-ray: Lung fields clear; normal size and shape of the chest wall and main structures in the chest. No cardiomegaly or other acute findings.
EKG: Atrial fibrillation with a ventricular rate of 65. Acute inferior ischemic changes noted – ST elevation in III & aVF.
Cardiac monitoring: Sinus rhythm with episodes of atrial fibrillation, ventricular rate 60s-70s.
- Heparin lock x 2
- Oxygen 3 liters/minute via nasal cannula
- Aspirin 325 mg
- Nitroglycerin drip at 30 µg/min
- Cardiac monitoring
- TPA 90-minute protocol
- Heparin IV 5,000-unit bolus followed by 1,000 units/hour
ASSESSMENT: Acute inferior myocardial infarction.
PLAN: Patient admitted to CCU under the care of Dr. ABC.
Code the Diagnosis
I22.1 Subsequent ST elevation (STEMI) myocardial infarction of inferior wall
I21.02 ST elevation (STEMI) myocardial infarction involving left anterior descending coronary artery
I25.10 Atherosclerotic heart disease of native coronary artery without angina pectoris
I10 Essential (primary) hypertension
F17.210 Nicotine dependence, cigarettes, uncomplicated
Z79.82 Long term (current) use of aspirin
Z79.899 Other long term (current) drug therapy
Rationale: According to the guidelines, since the patient had a prior MI within the past four weeks, this is considered a subsequent MI. Guideline I.C.9.e.4 states that if subsequent MI infarction is noted (category I22 code), an active MI (category I21) code must also be reported. In this case, the prior heart attack is stated to have occurred one week prior in the left anterior descending artery. The patient is presenting for care of a new MI, so the I22 code for the subsequent MI is sequenced first.
Note, coders cannot assume documented chest pain is angina. The provider must specifically document that the patient is experiencing angina in order to code it as such.
The patient has coronary artery disease of a native vessel, hypertension, nicotine dependence, smoking two packs a day, and is currently taking aspirin and hydrochlorothiazide (HCTZ). It is important to report all of these, as the patient is presenting to the ED for treatment of a cardiac-related problem.
2022 ICD-10-CM code book
2022 ICD-10-CM Official Guidelines for Coding and Reporting