Updated on: July 9, 2018

Type 2 Myocardial Infarction: Not a Fake Diagnosis

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Original story posted on: July 6, 2018

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ICD-10 code I21.A1 identifies Type 2 MI.

Over the past two months, I have been making the rounds speaking at regional and national conferences and going on-site for my consulting business. Many of you have approached me and assured me that the message I am trying to convey is indeed the message you are receiving.

I am not about the money – I am intent on getting providers to document accurately, specifically, and sufficiently to take excellent care of patients and to demonstrate how sick and complex they are. This optimizes quality metrics and reimbursement while preventing unwarranted hospital-acquired conditions (HACs) and patient safety indicators (PSIs). I never endorse exaggerating or upcoding. I believe I am actually quite conservative. I’d rather get it right up front than to have to fight a denial on the back end.

On June 20, I did a webinar on myocardial infarction (MI) – which, of course, included Type 2 myocardial infarctions. There has been some pushback from some individuals who decry the existence of this clinical entity and feel it is a “made-up diagnosis” that serves to jack up the DRG. They believe using it undermines the credibility of physician advisors and even have suggested that it harms patients.

Recently, our good friend Ron Hirsch (Ronald Hirsch, MD) brought to my attention an article in Circulation published online June 11, titled, “Type 2 Myocardial Infarction – Diagnosis, Prognosis, and Treatment,” by Cian McCarthy et. al. out of Massachusetts General Hospital and Brigham and Women’s Hospital. This article validated my viewpoint that Type 2 myocardial infarction is clinically relevant and important.

Their conclusion is this: “the diagnosis of Type 2 MI is associated with a poor prognosis: less than 40 percent of patients will live five years past their diagnosis.” They go on to explain that the poor prognosis is not surprising, because “Type 2 MI typically occurs among older patients with greater comorbidities and is identified in the context of hemodynamic instability.” The article goes on to note that “most deaths among patients with Type 2 MI are due to non-cardiovascular causes,” but that “approximately 30 percent of patients will have a cardiovascular event over five years,” which may even exceed that for patients with Type 1 MIs.

The article notes that there is precious little data and evidence-based guidelines regarding Type 2 MI. I am certain the fact that we didn’t have a way to separate out Type 2 MI from Type 1 MI in the ICD-10-CM code set strongly contributed to this shortfall. This was resolved in October 2017, when we got the unique code I21.A1 identifying Type 2 MI. We are now in a better position to be able to determine whether Type 2 MI demands its own treatment, or as has been the case in the past, you just treat the underlying condition. Insurance companies will have the ability to adapt their actuarial analyses, if needed.

I never recommend diagnosing and documenting conditions that are not present. I just want providers to practice excellent medicine and not to miss diagnosing and documenting conditions that are present. I say it harms patients if you don’t pick up the Type 2 MI, because it portends a worse prognosis. As Hippocrates would say, “primum non nocere” (first, do no harm).

 

Program Note:

Listen to Dr. Remer every Tuesday on Talk Ten Tuesday, 10 a.m. ET.

Erica E. Remer, MD, FACEP, CCDS

Erica Remer, MD, FACEP, CCDS has a unique perspective as a practicing emergency physician for 25 years, with extensive coding, clinical documentation improvement (CDI), and ICD-10 expertise. As a physician advisor for University Hospitals Health System in Cleveland, Ohio for four years, she has trained 2,700 providers in ICD-10, closed hundreds of queries, fought numerous DRG clinical determination and medical necessity denials, and educated CDI specialists and healthcare providers with engaging, case-based presentations. She transitioned to independent consulting in July 2016. Dr. Remer is a member of the ICD10monitor editorial board and the co-host of Talk Ten Tuesdays. She is also on the board of directors of the American College of Physician Advisors.

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