1. Circulatory System HS317b – Coding & Classification of Health Data

2. 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

3. Terminology - confusing MI Non Q Wave Non-ST elevation MI ST elevation MI Q Wave Anterior MI Inferior MI

4. Terminology-See Inclusions I21.0-I21.3Acute myocardial infarction (includes Q Wave) I21.4 Acute subendocardial myocardial infarction (Includes:Non-Q-wave myocardial infarction) I21.9Acute myocardial infarction, unspecified (Myocardial infarction (acute) NOS)

5. 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  I25.8Other 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)

6. 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)

7. 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

8. 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

9. Old Myocardial Infarction I25.2Old myocardial infarction  Considered a ‘history of’  Assign 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

10. I24 Other acute ischemic heart diseases Use for terms:  Missed MI  Aborted MI  Averted MI

11. Mandatory Intervention 1.ZZ.35.HA-C1 Pharmacotherapy, total body NEC, using antithrombotic agent  Intent: reperfusion of heart  Examples: Streptokinase or Urokinase  Mandatory

12. 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?

13. 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

14. 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

15. 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.

16. 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

17. Other Interventions 1.IJ.50.~~ Angioplasty (Dilation, coronary arteries)  Mandatory to include cardiac catheterization with attribute intraoperative 1.IJ.57.~~ Endarterectomy (Extraction, coronary arteries)

18. 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

19. 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

20. 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

21. 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

22.  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,…..

23. Rationale  Complication of CHF is within the postoperative monitoring period of 96 hours  External cause mandatory. Cause-effect relationship.  Not a pre-existing condition

24. 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

25. Which Rules to Apply? I97.1 Other postprocedural disorders of circulatory system, NEC I97.8Other postprocedural disorders of circulatory system, not elsewhere classified T81.88 Other complications of procedures, not elsewhere classified I50.0Congestive heart failure

26. 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.

27. Pleural Effusion & CHF Patient comes into hospital with exacerbation of CHF and pleural effusion. Thoracentesis is done to treat the pleural effusion.

28. Rules for Pleural Effusion (M or 1) I50.0Congestive heart failure (1) J90Pleural effusion, not elsewhere classified 1.GV.52.HA Drainage pleura

29. 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

30. Atrial Fibrillation Classified as a functional disturbance  Any code in range of I44 – I50 is a functional disturbance AF following open-heart surgery  Occurs within postop monitoring period or chart documentation indicates related to surgery  Not pre-existing

31. Atrial Fibrillation  I97.1 (2) Other functional disturbance following cardiac surgery  I48.0 (3) Atrial Fibrillation  Y83.~ Surgical operation

32. 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

33. 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

34. 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.

35. 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

36. 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.

37. 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.

38. Interventions Cardiac Catheterization  Affects CMG assignment  Mandatory Cardiopulmonary bypass  Affects CMG assignment  Mandatory

39. 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)

40. 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

41. CABG No to heart pump  No to cardiac cath – CMG 184 Major Cardio- Thoracic Procedures without heart pump and without cardiac cath Yes to heart pump  Yes to cardiac cath – CMG 183 Major Cardio- Thoracic procedures with Heart Pump with Cardiac Cath

42. 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