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The information provided is intended to assist with support for the documentation accuracy of the
diagnoses codes reported to Highmark and not intended to influence clinical or coding judgement.
Information regarding any law or regulation does not constitute legal or tax advice and is subject to change
based upon the issuance of new guidance and/or change in laws or regulations. Providers should still
reference official ICD-10-CM coding guidelines and coding manuals or electronic coding software for
accurate reporting of compliant diagnosis codes.
Disclaimer
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Agenda
1. Discuss Acute vs Old MI
2. Identify the types of CHF
3. Discuss Angina
4. Review supportive Documentation for MI and CHF
Acute, Subsequent and Old MI
• Acute MI
• Subsequent MI
• Old MI
Key Terms
Coding Acute MI
The term “Acute” MI is used:
• When the admission is for initial care
• For the first 4 weeks after onset
• Subsequent MI occurs within the 4
weeks of the initial MI.
Subsequent and Old MI
• The term “Old MI” is used for healing
or healed MI not requiring further care.
Highmark Inc. CONFIDENTIAL AND PROPRIETARY
Types of Angina
Angina is not a disease in itself,
but a symptom of an
underlying condition which causes
ischemia to the heart muscle.
Angina
In the outpatient setting:
• Patient is symptomatic
• Treatment includes nitrates or
anti-anginal medications
• The condition is addressed
Unstable Angina
Outpatient vs Inpatient Setting
Unstable Angina ═ Medical Emergency
Not typically coded in outpatient setting
unless patient sent emergently to ER.
Unstable Angina
Inpatient Setting
• If the unstable angina does not
evolve into an MI it would be coded
to unstable angina.
• If the unstable angina does evolve
into an MI, you would only code the
MI.
Highmark Inc. CONFIDENTIAL AND PROPRIETARY
Angina
Coding Angina
Unstable Angina
• I20.0 Unstable Angina
Heart Failure
• Heart failure occurs when the heart
cannot fill, making it unable to
pump enough blood to the body.
• Symptoms of heart failure:
✓ Build up of extra fluid (edema)
o Typically in the legs
✓ Shortness of breath
✓ Fatigue
Identifying Congestive Heart Failure
• Chest X-Ray
• EKG
• Echocardiogram
• MRI
Tools to Diagnose CHF
Types of Heart Failure
Documentation Guidelines
M – MONITOR
Signs, symptoms, disease progression, disease regression
E – EVALUATE
Test results, medication effectiveness, response to treatment
A – ASSESS/ADDRESS
Ordering tests, discussion, review records, counseling
T – TREAT WITH A PLAN OF CARE
Medications, therapies, other modalities
Industry Standard M-E-A-T
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1. Monitor
2. Evaluate
3. Assess/ Address
4. Treat
1. Monitor
2. Evaluate
3. Assess/ Address
4. Treat
Proper
documentation
requires one of
these four
elements for
each diagnosis
Acute Myocardial Infarction
• Codes for Acute MI (begin with I21) may continue to be used for encounters
occurring while the myocardial infarction is less than, or equal to, four weeks old.
• For encounters after the 4 week timeframe, if the patient is still receiving care related
to the myocardial infarction, the appropriate aftercare code should be assigned and
not a code from I21.
Myocardial Infarction
Subsequent and Old MI• A subsequent MI is when a patient has suffered a type1, or unspecified, AMI and
has a new AMI within the initial 4 week time frame, you would use a code from
both the I21 and I22 category based on the ICD-10 coding guidelines and reason
for encounter.
• For old or healed myocardial infarction not requiring further care, assign code
I25.2, Old myocardial infarction.
• Documentation should include the exact date of type of each MI.
Myocardial Infarction
• Often misdiagnosed as “SOB” or “edema”
• Quantify ECHO findings
• Link medications to condition
• Compensated heart failure ≠ resolved heart
failure
• Diastolic dysfunction is not synonymous with
diastolic heart failure
• Distinguish acute, chronic, or acute on chronic
Heart Failure
Highmark Inc. CONFIDENTIAL AND PROPRIETARY
• Angina is a symptom of an underlying
heart problem which causes ischemia to
the heart muscle.
• Document cause of angina and any
underlying or associated conditions.
• Document any medications used for
treatment, and link them to the angina.
• Documenting a surgical history of
bypass graft will help determine
appropriate diagnosis code for continued
angina.
Angina
Clear, Concise Documentation
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Key terminology
–Primary vs. secondary
–Due to…
–Severity
Key terminology
–Acute vs. chronic
–Compensated
–Stable/unstable
CMS DocumentationUpdates
• Electronic signatures require the date
and time on the signature line.
• Providers must sign notes within 180
days of encounter.
Provider Signature
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Source: Contract-Level RADV Medical Record Reviewer Guidance
Thank You!
HCC University is a provider coding resource on NaviNet. It contains guides to assist with documentation and coding according to CMS documentation standards and ICD-10-CM coding requirements.
Available Resources
Highmark Inc. CONFIDENTIAL AND PROPRIETARY
1. Log into NaviNet
2. Navigate to the Provider Resource Center
3. Select “Education/Manuals” from the menu bar to expand the selection
4. Select “Coding Education/HCC University” to open the page with corresponding resources
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