Scenario 4: Subsequent AMI

Chief Complaint 

• Follow up after my second heart attack.

History 

• 81 year old male retired professor presents for follow up visit after hospital admission for NSTEMI; he was discharged five days ago. Currently denies chest pain, shortness of breath. Able to walk without symptoms.

• Medical history remarkable for CAD requiring CABG times four, PVD, bilateral carotid stenosis, hypertension, dyslipidemia, COPD, emphysema, renal artery stenosis, CHF with diastolic dysfunction, and NSTEMI. 

• NSTEMI #1 while patient was on a cruise about three weeks ago. Limited data indicates ECG findings included ST depression, rise in troponin. 

• NSTEMI #2: myocardial infarction with rise in cardiac biomarkers with no ST changes on EKG, seven days ago. Partially reversible inferorposterior wall defect by perfusion study. Probably represents disease of vein graft to RCA. 

• Prior evaluation: Extensive vascular disease. Multiple revascularization procedures done in staged manner due to chronic renal failure. Catheterization: patent grafts. Peripheral angiogram: stenosis of renal arteries and lower extremity circulation. Duplex of renal arteries: bilateral renal artery stenosis. • Social History: cigarette smoker for 64 years, ½ pack per day. No alcohol or drug use.

 • Family History: cancer, diabetes, kidney disease. 

• Current medications: hydrochlorothiazide – telmisartan, simvastatin, clopidogrel, amlodipine, metoprolol succinate, aspirin. 

• Review of Systems: Denies fever, chills, cough, nausea, vomiting, TIA, syncope, rash, or melena. 

Exam

 • Pleasant elderly male in no acute distress. 

• Vital signs: BP 150/80. HR: 74. Respirations: 18/min. Afebrile. 

• HEENT: EOMI, PERRLA. 

• NECK: Supple. No JVD. Positive right carotid bruit. 

• CHEST: Clear to auscultation. Bilateral equal breath sounds. Has cough. 

• CV: RRR, S1 and S2 present. No S3. Positive S4. Crescendo-decrescendo systolic murmur 3/6 heard in aortic valve/apex area. 

• PERIPHERAL VASCULAR: Skin pink, warm and dry and well perfused. No clubbing or cyanosis. Plus 2 pitting ankle edema. 

• ABDOMEN: Soft, non-tender without masses, or organomegaly. Active bowel sounds. 

• NEURO: Patient A&Ox3, appropriate. No focal deficits noted.

Assessment and Plan 

• Hemodynamically and clinically stable today. 

• Continue medical therapy. 

• Schedule doppler echocardiogram to evaluate of new murmur.

 • Discussed with patient the need for optimal compliance including pharmacologic regimen and lifestyle modifications. 

• Patient continues to smoke, albeit less, and is not interested in quitting at this time. 

Summary of ICD-10-CM Impacts 

Clinical Documentation 

1.In ICD-10, there are numerous changes for cardiac related medical conditions. The changes include but are not limited to: 

• Inclusion terms of ST elevation (STEMI) and non-ST elevation (NSTEMI) myocardial infarction are made to reflect the national standard guidelines of The American College of Cardiology and the American Heart Association for classifying patients with acute coronary syndrome For example, the non-ST elevation MI term replaces the older terminology of non-Q wave MI. 

• The time frame for acute myocardial infarction codes has changed from 8 weeks or less in ICD-9-CM to 4 weeks or less in ICD-10-CM. 

• When the patient has a new AMI within the 4 week time frame of the initial AMI, this information should be documented. 

• Delineate in your documentation whether an MI no longer requires further care. That information allows a clinical coder to determine whether the patient has an old or a healed MI. If after 4 weeks they still need care use “aftercare” in ICD-10-CM. 

2.If applicable, note items such as presence or absence of an increase in cardiac enzymes or troponin, or ECG findings (e.g., ST elevation, ST depression, T inversion, new pathological Q waves) in your documentation. 

3.In coding this scenario we assumed that the carotid stenosis is resolved as well as the renal artery stenosis, since this encounter is post revascularization procedure. While it may be controversial, we do not think that a code for the CABG is sufficiently supported in the documentation, although we recognize that the stress test findings may be interpreted as supporting atherosclerosis of the grafts as well as of the native arteries. 

4.In ICD-9, the clinician needs to document that the patient smokes tobacco or uses tobacco. In ICD-10-CM the amount of detail increases as there are 20 choices for nicotine dependence. In ICD-10, the required documentation includes the type of tobacco product used and whether or not there are nicotine-induced disorders such as remission or withdrawal present. Classifications for nicotine dependence include: uncomplicated, in remission, with withdrawal, or present with other nicotine induced disorders. In this note, even though the patient’s health condition is complicated and he has multiple comorbid conditions, his nicotine dependence is classified as uncomplicated as it does not meet the other classifications since as he is not attempting to quit.