Circulatory System
HS317b – Coding &
Classification of Health Data
Acute Myocardial Infarction
Folio lookup
 myocardium, myocardial (acute or with a stated
duration of 4 weeks or less) I21
 – – chronic or with a stated duration of over 4
weeks I25.8
 – – healed or old I25.2
 – – nontransmural I21.4
 – – other
 – – – complications I23.88
 – – past
Terminology - confusing
MI
 Non Q Wave
 Non-ST elevation MI
 ST elevation MI
 Q Wave
 Anterior MI
 Inferior MI

Terminology-See Inclusions
I21.0-I21.3 Acute myocardial infarction
(includes Q Wave)
 I21.4 Acute subendocardial myocardial
infarction (Includes: Non-Q-wave
myocardial infarction)
 I21.9
Acute myocardial infarction,
unspecified (Myocardial infarction
(acute) NOS)

Coding Myocardial Infarctions

Overlapping sites classified to ‘other sites’
 Either

I21.2 or I21.42 …’other sites’
Acute phase is 28 days
 After
28 days consider it a chronic condition
 I25.8
Other forms of chronic ischaemic heart
disease


Any condition in (I21-I22) and (I24.-) specified as chronic or
with a stated duration of more than 4 weeks (more than 28
days) from onset.
Code this if patient currently receiving acute care
(observation, evaluation or treatment)
Re-infarction > 28 days

I22.~
Subsequent myocardial infarction
 Criteria;


Includes: further extension of myocardial infarction
recurrent
 Diagnosis

typing based on ‘significance’
Excludes: specified as chronic or with a stated
duration of more than 4 weeks (more than 28
days) from onset (I25.8)
Other conditions following MI

I23 Certain current complications
following acute myocardial infarction
 Haemopericardium
 Atrial
or Ventricular septal defect
 Rupture of cardiac wall, chordae tindineae, or
papillary muscle
 Thrombosis, Papillary muscle dysfunction,
pericarditis, postmyocardial infarction angina,
etc
Exclusions to using I23.~
 Used
for specific complications that may
occur following acute MI (usually 2-7 days
post MI)
 When condition is concurrent with acute
myocardial infarction (I21-I22)

It is included in the acute myocardial infarction
code, don’t code separately
Old Myocardial Infarction

I25.2
Old myocardial infarction
 Considered
 Assign
a ‘history of’
if:
The old MI occurred more than four weeks ago (28
days)
 The patient is currently not receiving care
(observation, evaluation or treatment) for the OLD
MI

I24 Other acute ischemic heart
diseases

Use for terms:
 Missed
MI
 Aborted MI
 Averted MI
Mandatory Intervention

1.ZZ.35.HA-C1 Pharmacotherapy, total
body NEC, using antithrombotic agent
 Intent:
reperfusion of heart
 Examples: Streptokinase or Urokinase
 Mandatory
Ms. M. who was known to have coronary
atherosclerosis presented to the emergency
department with unstable angina. She was
subsequently admitted to undergo coronary
artery bypass grafting (CABG).
Final Dx: CAD with unstable angina
What is MRDx?
Coronary Artery Disease
Terminology: chronic ischemic heart
disease, atherosclerotic heart disease
(ASHD), coronary artery disease (CAD),
coronary atherosclerosis, arteriosclerotic
heart disease
All coded to I25.1~ atherosclerotic heart
disease.
specificity – native/graft vein/artery
Angina & CAD


A history of angina with no documented
episode occurring during the patient’s stay in
hospital is simply a risk factor and may be
coded at the facility’s discretion with
diagnosis type 3
RULE: angina may only be coded as a
significant diagnosis when there is a
documented episode of angina on admission
or at any given time during the hospital stay
Diagnosis typing for CAD

In scenario where physician writes CAD with angina as
MRDx ask yourself where is treatment being directed.

Patients can be treated with either percutaneous
transluminal coronary angioplasty or coronary artery
bypass graft

Depends on circumstances and whether course of
treatment was directed at unstable angina.
CABG – 1.IJ.76.~~




Tissue used for the bypass is coded
i.e.: procurement for saphenous vein or radial
artery
When pedicled and free autografts are used the
qualifier for combined grafts should be selected
Inherent in CABG code are hypothermia,
cardioplegia and chest tube insertions
Code cardiopulmonary bypass (Mandatory)
 Affects
CMG assignment
Other Interventions

1.IJ.50.~~ Angioplasty (Dilation, coronary
arteries)
 Mandatory
to include cardiac catheterization
with attribute intraoperative

1.IJ.57.~~ Endarterectomy (Extraction,
coronary arteries)
Complications of CAD
Follow postprocedural conditions and
complications rules
 If occlusion, thrombosis or stenosis of
coronary artery grafts occur:

 Consider
it T82.8 Other complications of
cardiac and vascular prosthetic devices,
implants and grafts.
 If due to an atheroma—indicative of natural
process of disease rather than a
complication of bypass graft
Natural progress of disease versus
occlusion complication

Thrombus formation
 Within
a month T82.8
 Over a year likely natural progression

Atherosclerosis changes
 Within
a month—possibly due to a technical
error
 Over a year natural progression
Heart Failure/Cardiac Insufficiency
Following surgery, patient was taken to the
ICU for post-operative monitoring where
she developed congestive heart failure
within the first 24 hours.
 The CHF was not a pre-existing condition

Folio look-up for CHF
Failure
 heart (acute) (sudden) I50.9
 – – complicating
 – – – anesthesia (general) (local) or other sedation
 – – – –– – – surgery T81.8
 – cardiorespiratory (see also Failure, heart) R09.2
 – – specified, during or due to a procedure T81.8
 – – – long term effect of cardiac surgery I97.1
 T81.88
(2) Other complications of procedures,
NEC
 I50.~ (3) Heart failure
 Y83.9 (9) Surgical procedure, unspecified as
the cause of abnormal reaction of the patient,
or of later complications,…..
Rationale
 Complication
of CHF is within the
postoperative monitoring period of 96 hours
 External cause mandatory. Cause-effect
relationship.
 Not a pre-existing condition
What if patient developed an episode of
congestive heart failure on day 8 of her
stay and Lasix was added to her
treatment, how would you code this?
 CHF is not pre-existing

Which Rules to Apply?
I97.1 Other postprocedural disorders of
circulatory system, NEC
 I97.8
Other postprocedural disorders of
circulatory system, not elsewhere
classified
 T81.88 Other complications of
procedures, not elsewhere classified
 I50.0
Congestive heart failure

Late complication



I97.1 (2) other postprocedural disorders of
circulatory system, NEC
I50.0 (3) Congestive heart failure.
Rationale:
 Occurring
during hospitalization
 External cause not required



> 96 hours, < 15 days
No documented evidence of any relationship to the
intervention.
Apply External Cause if physician indicates postop.
Pleural Effusion & CHF
Patient comes into hospital with
exacerbation of CHF and pleural effusion.
 Thoracentesis is done to treat the pleural
effusion.

Rules for Pleural Effusion
(M or 1) I50.0
Congestive heart failure
 (1) J90 Pleural effusion, not elsewhere
classified
 1.GV.52.HA Drainage pleura

Rules for Pleural Effusion

Rationale:
 If
Pleural effusion is documented on X-ray
only & no intervention this diagnosis should
not be coded. (Included in diagnosis of CHF)
 If treatment is directed to effusion by
therapeutic thoracentesis or chest tube
drainage

the pleural effusion may be coded as an additional
diagnosis
Atrial Fibrillation

Classified as a functional disturbance
code in range of I44 – I50 is a functional
disturbance
 Any

AF following open-heart surgery
 Occurs
within postop monitoring period or
chart documentation indicates related to
surgery
 Not pre-existing
Atrial Fibrillation
 I97.1
(2) Other functional disturbance
following cardiac surgery
 I48.0 (3) Atrial Fibrillation
 Y83.~ Surgical operation
AF > 95 hours, < 15 days
Not related to surgery by documentation
 No assumed cause & effect relationship

 I97.8
(2) other postprocedural disorders of
circulatory system, NEG
 I48.0(3) AF
Folio lookup – Cardiac Arrest

Arrest, arrested
 -Cardiac
I46.9
 - - complicating
 - - - surgery T81.8
 - - postoperative I97.8
 - - - long term effect of cardiac surgery I97.1
 Cannot use both I97.8 and T81.88
Cardiac Arrest

Not occurring postprocedural
 Only
code if resuscitative intervention is
undertaken
I46.0 Cardiac arrest with successful resuscitation
 I46.9 Cardiac arrest unspecified


Occurring as expected terminal event
 Code
only underlying or contributing
condition.
Cardiac Arrest following Intervention

< 96 hours
 Documentation
 T81.88
(2) Other complications of procedures,
NEC

> 96 hours, < 15 days
 I97.8
(2) other post-procedural disorders of
circulatory system
 I46.0 (3) Cardiac arrest with successful
resuscitation
Resuscitation, heart

New for April 2006
 Code
resuscitation, heart NEC when CPR is
performed, regardless of outcome.
 Code
1.HZ.09.~~ Stimulation, heart NEC
when CPR is followed by defibrillation.
Resuscitation, heart – why?
In 2006 the Grouper is going to use high
cost interventions as a factor in the
Resource Intensity Weights methodology.
This will not affect the CMG but will be
applied at the RIW stage.
 CPR
is such an intervention. It will be
mandatory to code anytime it is performed.
Interventions

Cardiac Catheterization
 Affects
CMG assignment
 Mandatory

Cardiopulmonary bypass
 Affects
CMG assignment
 Mandatory
Classification based on MRDx

MCC 5 Diseases and Disorders of the
Circulatory System
 MCC
5A Cardiac Diseases and Disorders
 MCC 5B Vascular Diseases and Disorders
 CMG assigned based on whether procedure
was undertaken or not (surgical or medical
partition)
CMG Examples
Heart or Lung Transplant – CMG 175
 Tracheostomy and Gastrostomy procedure
– CMG 40


Surgical Procedures broken down based
on heart pump usage and/or cardiac
catheterizations
CABG

No to heart pump
to cardiac cath – CMG 184 Major CardioThoracic Procedures without heart pump and
without cardiac cath
 No

Yes to heart pump
to cardiac cath – CMG 183 Major CardioThoracic procedures with Heart Pump with
Cardiac Cath
 Yes
Acute Myocardial Infarction

Factors influencing CMG Assignment
 If
shock or pulmonary embolism
 LOS > 4 days
 If CHF present
 Is there ventricular tachycardia
 Angina present
 Cardiac Catheterization