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Thread: ICD-9 Code(s)

  1. #1

    Default ICD-9 Code(s)

    How would you code a patient who was discharged from the hospital with a diagnosis of probable myocardial infarction without a history of MI in the past?

  2. #2
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    You can not code possibles. Would need to code symptoms (i.e., chest pain, shortness of breath, nausea, pain in arm, etc), or any abnormalites of tests(i.e., increased cardiac enzymes, abnormal ekg) that were performed during the admission.

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    The ICD-9 (Ingenix version pages 27/28) guidelines specifically state that for inpatient encounters only do you code possible's, likelies etc. So you would code the MI and the Hx of MI ICD-9 codes.

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    Quote Originally Posted by mworcester View Post
    The ICD-9 (Ingenix version pages 27/28) guidelines specifically state that for inpatient encounters only do you code possible's, likelies etc. So you would code the MI and the Hx of MI ICD-9 codes.
    That instruction applies only to the inpatient facility coder, not to the physician coder. So it depends on whom you are coding for, the hospital or the physician

    Debra A. Mitchell, MSPH, CPC-H

  5. #5

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    The exact question is: If a patient were discharged from the hospital with a diagnosis of probable myocardial infarction without a history of MI in the past, what ICD-9 code would the coder document for this stay?

    The diagnosis is probable myocardial infarction but there is no history of it, so I say none.

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    Quote Originally Posted by arbrown2002 View Post
    The exact question is: If a patient were discharged from the hospital with a diagnosis of probable myocardial infarction without a history of MI in the past, what ICD-9 code would the coder document for this stay?

    The diagnosis is probable myocardial infarction but there is no history of it, so I say none.
    If this is a test/quiz question, then you need to know from what perspective it is being delivered; the physician or the facility. If the physician coder is coding the discharge record they would need to code the symptoms, if the facility coder were coding the same statement they would code the acute MI. If the patient were outpatient there would not be a discharge statement. But if they were then the facility coder would do the same as the physician coder.
    Inpatient facility coders are the only ones that may code possible, probable, suspected, and rule out, as though it exists.

    Debra A. Mitchell, MSPH, CPC-H

  7. #7

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    I would not code MI because it's probably meaning not really for sure. Unless you're an inpatient hospital coder
    Last edited by KCCODER; 09-27-2012 at 02:31 PM.

  8. #8

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    Do not code probable. Code the symptoms.

    For a hx MI, code hx MI. That is all you are able to code.

    The codes themselves will paint the picture - this person has a hx of MI and they are experiencing these related symptoms now. Though it cannot be coded as an acute MI since it is only probable, it still illustrates that MI is suspected.

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