1. Heart Conscious Making Sense of Elevated Troponins
Jill O’Brien, MD
Medical Director Case Management
Physician Advisor to CDI/Coding
The Miriam Hospital

3. Clarifying Principles
Clear Definition for Type 2 MI
Expanded Rationale for Elevated Troponins without MI
Acknowledgement that often several processes are occurring in tandem resulting in elevated troponin
What’s Missing?
Demand Ischemia

6. MI versus Myocardial Injury
Troponin Elevation reflects an injury to myocytes but does not indicate the underlying pathophysiological mechanism.

7. MI versus Myocardial Injury
“Although myocardial injury is a prerequisite for the diagnosis of MI, it is also an entity in itself”
“To establish the diagnosis of MI, criteria in addition to abnormal biomarkers are required.”
“Clinicians must distinguish whether patients have suffered a non- ischemic myocardial injury or one of the MI subtypes”
“If there is no evidence to support the presence of myocardial ischemia, a diagnosis of myocardial injury should be made”

10. Cellular Factors Leading to Release of Troponin
Mechanical Stretch
Normal Cell Turnover
Apoptosis (organized cell death do to other factors)
Increased cell permeability
Formation and release of membranous blebs
Myocyte necrosis

11. Causes of Elevated Troponin in CHF
Type 1 MI
Coronary thrombosis leading to cardiac dysfunction, reduced cardiac output and thus heart failure symptoms
Type 2 MI
During heart failure exacerbation: Increased transmural pressure, small-vessel coronary obstruction, endothelial dysfunction, anemia, hypotension
Myocardial Injury with cellular death
During heart failure exacerbation: Wall stretch, direct cellular toxicity related to inflammation

12. Causes of Elevated Troponin in Critical Illness
Type 1 MI
Plaque disruption leading to thrombosis in a coronary artery
Type 2 MI
Increased myocardial oxygen demand
Myocardial Injury with cellular death
Endotoxin release resulting in local cell death and reduced cardiac function

13. When to use “Demand Ischemia”
Potential Clinical Scenario:
Increased heart rate for “demand reason” with ischemic changes on EKG but NO troponin elevation
This term in confusing
Troponin elevation from ischemia indicates myocardial injury and if there is a rise/fall of troponins with evidence of ischemia this denotes a “Myocardial Infarction”
I’m telling staff if you are not using this term for a clinical scenario such as outlined above don’t use the terminology at all.

14. Who’s seen this?
“I’m a bit concerned that we are labeling the population of RI as having varying degrees of cardiac ischemia which will affect everyone’s ability to be insured both medically and for life.
I find these definitions flawed and their use disabling to our population on paper.”
4th Universal Definitions Helps the Cause:
Myocardial Injury without Ischemia
But there’s no ICD-10 Code… YET

15. Bridging the Gap Assumptions about clinicians:
Most have not read the 4th Universal Definition for MI
Demand Ischemia, as a term, has been explained in a variety of ways that do not always make sense to providers clinically
Feel it necessary to write something when they see a positive troponin to avoid “the Query”
Are feeling uncomfortable with the frequency they are diagnosing a type 2 MI but recognize that the abnormal troponin signifies an increase risk to their patients in the short and long term

16. Bridging the Gap Coding/CDI side:
Terms like: elevated troponin, troponinemia or combinations of terminology are non-specific and can signify different pathophysiology
End Coder/ICD 10 limitations for “non-ischemic myocardial injury”
Elevated troponin  can’t be coded
Myocardial injury  implies trauma

17. Bridging the Gap GOAL: Offer definitions to match clinical reasoning
Include definitions on all queries
Honestly present the lack of a “codable” diagnosis for “myocardial injury without ischemia”
Lobby to AHIMA/ACDIS to address ICD-10 short-comings

18. Feeling Stagnant Understanding Acuity of VTEs

19. DVT CHRONIC ACUTE New Clot
Time frame for acute episode not agreed upon in literature
Abrupt onset leg swelling, redness, pain
Usually brought on by venous stasis, hypercoagulability and/or endovascular insult
Treat with anticoagulation for 3- 6months
Old clot that has not resolved despite appropriate management with blood thinners
Clot scars vessel and causes complications due to venous stasis
Patients can have chronic swelling, skin changes, ulcerations, recurrent infections
Management can include: surgical repair, stenting, TEDS, anticoagulation

20. Ultrasound Diagnosis - DVT
ACUTE
CHRONIC
Small, irregular vein
Non-compressible
Thrombus is well adherent and hyperechoic (bright)
Collaterals present
Distended Vein
Partially Compressible Vein
Thrombus visualized – hypoechoic (black)
No Collaterals

22. Pulmonary Embolism ACUTE CHRONIC New Clot
Symptoms of Chest Pain, Shortness of Breath
Patients can have hypoxia, tachycardia, hypotension
Diagnosed by CTA
Treatment with anticoagulation for 3-6months
Severe cases may require thrombolytics, EKOS, or embolectomy
Old clot that has not resolved despite appropriate management with blood thinners
Patients develop complications from Pulmonary Hypertension
Diagnosis can be by CTA but usually by V/Q scan; echo shows pulmonary hypertension
Management is with anticoagulation and possibly sildenafil

23. Coding Clinic Guidance
ICD-9-CM Coding Clinic, Fourth Quarter 2009 Pages: Effective with discharges: October 1, 2009

24. “History Of” Patient has had a DVT/PE in past
Coding Clinic (1st Q, 2011)
Patient has had a DVT/PE in past
Does not have complications of a “Chronic DVT/PE”
May or May Not be receiving anticoagulation

25. Take Home Points These diagnoses do not follow a continuum: Rather:
“History of”
Acute
Chronic

26. Bridging the Gap Assumptions about Clinicians:
We have no idea what time frame to utilize to define an acute clot
Chronic clots act very differently than acute clots and management can be very different or look very similar
We may not always write “history of” when creating our problem list, even though that is what we mean.
For instance: DVT – cont Coumadin, trend INR

27. Bridging the Gap Coding/CDI Side:
Acuity is necessary for precise coding
Treatment for all 3 types of clot can be the exact same which is challenging
End Coder Limitations:
Unspecified DVT/PE  Acute DVT/PE

28. Bridging the Gap
Consider Phase of Management when asking if a clot is acute
“Acute phase of Management”
Utilize imaging findings to help clarify clot type
Anticoagulation in a patient with “history of” is for prevention of new clot not treatment of an existing clot

29. Happy Valentine’s Day