MI codes I21.A1 vs I21.4

heartyoga

Guru
Messages
132
Location
Cookeville
Best answers
0
The cardiologist consult as ff:
Chief Complaint: Elevated troponin consistent with Non ST elevation myocardial infarction, afib w RVR, tachycardia bradycardia, acute CHF.

Assessment:
1. NSTEMI, acute but type 2 due to demand ischemia from tachycardia

This throws our coder off bec all she sees is type 2 = I21.A1.

I was explaining that the medical records is saying clearly it is NSTEMI. Maybe there are several types of NSTEMI medically that is not in the code book. Waiting to query the physician.

She also mentioned that the doctor has to go back and change/add addendum to the tachycardia as paroxysmal tachycardia to be able to code it I47.0-I47.9 if it is I21.A1.

She said the insurance would be looking at it and we would be "in trouble". Patient is traditional Medicare and we would "harm the patient" if she didn't code it correctly and if the coder of PCP sees type 2 she would code it as I21.A1 and our codes would be flagged by the insurance. Sigh...

All I know is the physician is doing his best to provide medical care to the patient, conveying his inputs based on his medical knowledge and experience to do what's best for the patient. I don't think he should be constrained in his documentation based on what is or what is not in the code book.

Inputs and suggestions are appreciated.

Thanks !
 

mitchellde

True Blue
Messages
13,490
Location
Columbia, MO
Best answers
1
For the MI - a type 2 NSTEMI is secondary to ischemia from a supply and demand mismatch. It is marked by nonST elevation. So you see the term type 2 MI is the same as saying type 2 MI and so they created the new type 2 MI code to distinguish it from any other NSTEMI so the I21.A1 code is correct
For the tachycardia - in my opinion it is wrong to query the provider to document a specific diagnosis. I don’t feel this is ever appropriate. Unless you truly feel he has evidence to be more specific. You could query as to whether he can document the tachycardia more specifically but honestly I just feel that is wrong. I feel if he felt it could be more specific he would have said so.
 

heartyoga

Guru
Messages
132
Location
Cookeville
Best answers
0
So we just code it as I21.A1 without the tachycardia bec we cannot code it as paroxysmal tachycardia ? Under the definition in the book, Code also the underlying cause, if known and applicable, such as : anemia, COPD, heart failure, paroxysmal tachycardia, renal failure, shock.

Is this a case of cause unknown, bec it is written in the chart "demand ischemia from tachycardia" not from paroxysmal tachycardia?

Thank you Ms Mitchell for helping us.
 

mitchellde

True Blue
Messages
13,490
Location
Columbia, MO
Best answers
1
on further review, the code also note no longer exists with I21.A1 it is now a codes first note so I went to the coding clinic and it does state that there must be a cause and effect relationship so there must be documented a precipitating cause. The code first note makes the I21.A1 code a secondary only allowed code. So you will need confirmation of one of the conditions listed as the causal condition. Apologies for my earlier Reply as I failed to notice the change in the code for 2020.
 
Last edited:

heartyoga

Guru
Messages
132
Location
Cookeville
Best answers
0
We queried the physician and he did say that he meant paroxysmal tachycardia owing to the fact that patient also had atrial fibrillations, paroxysmal.. Coder says NOT GOOD ENOUGH, the physician has to have it documented, add the word "paroxysmal" to tachycardia, go to med records and add an addendum. Doctor said he is unable to do that, given that the medical facts and care has not changed, and this is only for coding purposes.
 

mitchellde

True Blue
Messages
13,490
Location
Columbia, MO
Best answers
1
There are different types of paroxysmal tachycardia and therefore different indications. The response you receive from the provider will depend on how you word a query. If the coder focused on information needed for coding, it is possible the provider became irritated and felt that enough information was there. You need to see if in fact the information is there. A provider does not need to use the exact wording in the code book but they do need to provide enough documentation that would mean the same thing. If there is not then you need to have a carefully worded query which focuses on the patient and the patients diagnosis and how the missing information will be beneficial. For instance you can point out that there are different types of paroxysmal tachycardia and from the information in the chart note it is unclear as to whether this is atrial or Supra ventricular, and can he clarify. But be sure the informs not there to make the determination.
as an analogy I had a provider document a pediatric patient with past seizure needing clearance for sports, he documented ongoing treatment but no seizures for one year. I inquired as to whether this was a seizure disorder as to be considered epilepsy or just a seizure disorder. There is a code in the epilepsy category for seizure disorder. The provider felt that it was an excellent question and proceeded to explain how to differentiate documentation of epilepsy and seizure disorder.
Hopefully this is of some assistance
 
Top