** This article was reviewed and updated on November 28, 2023.**
Acute Myocardial Infarction Coding
Acute myocardial infarction (AMI) coding is a critical skill that medical coders will likely encounter sometime during their coding career. This article dives into the complexities of AMI coding using the ICD-10-CM system to enhance coding accuracy.
Understanding Acute Myocardial Infarction
Defining the Condition and Its Prevalence
An acute myocardial infarction, also referred to as a myocardial infarction (MI) or a heart attack, occurs when the flow of oxygen-rich blood to a portion of the heart muscle becomes suddenly obstructed. This blockage, whether short-lived or prolonged for up to four weeks, causes tissue damage due to insufficient oxygen supply. The National Heart, Lung, and Blood Institute stresses the importance of restoring blood flow to prevent irreversible damage.
Other names for myocardial infarction include acute coronary syndrome, coronary thrombosis, and coronary occlusion. The term “myocardial” relates to the heart’s muscular tissue; “myo” means muscle, while “cardial” means heart. “Infarction” signifies tissue death caused by lack of blood supply.
AMI’s widespread impact is evident in the statistics the Centers for Disease Control and Prevention (CDC) provided:
- In the United States, a heart attack occurs every 40 seconds.
- Annually, around 805,000 Americans experience a heart attack. Of these, 605,000 people have had a first heart attack, and 200,000 already have a heart attack.
- About 1 in 5 heart attacks are silent, meaning the damage is done, but the person isn’t aware of it.
Root Causes of AMI
The leading cause of most myocardial infarctions is ischemic heart disease. However, some MIs are caused by a coronary artery spasm, but less frequently.
Ischemic Heart Disease
Ischemic heart disease, characterized by the accumulation of arterial plaque over years, is the primary cause of most AMIs. The gradual buildup of plaque, also known as atherosclerosis, causes the formation of blood clots that can partially or entirely block blood flow through a coronary artery. Immediate treatment is essential to prevent necrosis (death of body tissue ) and replace healthy tissue with scar tissue.
Other names for ischemic heart disease are coronary artery disease, coronary microvascular disease, coronary syndrome X, non-obstructive coronary artery disease, and obstructive coronary artery disease.
Coronary Artery Spasm
Although less common than ischemic heart disease, coronary artery spasms can trigger AMIs. These spasms, often occurring in coronary arteries unaffected by atherosclerosis, constrict blood flow through the artery. This constriction further emphasizes the urgency of early detection and treatment.
The cause of the spasm of a coronary artery is uncertain. Still, it may be related to taking drugs such as cocaine, emotional stress or pain, exposure to extreme cold, or cigarette smoking. According to Harvard Health Publishing, myocardial infarctions tend to happen more in men than women in early middle age. However, once menopause starts, a woman’s risk increases.
Signs and Symptoms
A heart attack does not always have symptoms, which is why it is referred to as a silent heart attack. When an AMI does present with symptoms, the symptoms can vary from one person to another and from one heart attack to the other in the same person. Diabetics may have no symptoms or very mild ones.
The most common symptoms for both men and women include chest discomfort, upper body pain, shortness of breath, cold sweats, extreme fatigue (especially in women), nausea, vomiting, and dizziness.
Multiple factors can increase the risk of AMIs, including smoking, hypertension (high blood pressure), high cholesterol level, an unhealthy diet, insulin resistance or diabetes, obesity, a sedentary lifestyle, age, family history, and preeclampsia during pregnancy.
Diagnosing an AMI
A physician may suspect a heart attack based on the patient’s symptoms, medical history, and risk factors for cardiovascular disease. Essential diagnostic tools include electrocardiograms (ECGs or EKGs), physical examinations focusing on the heart and blood pressure, and blood tests to detect heart muscle damage. Troponin is the most common blood test. Additional tests that may be necessary include an echocardiogram to view the heart muscle and heart valves and radionuclide imaging to detect areas of poor blood flow in the heart.
The specific treatment plan for an AMI depends on the patient’s condition and the immediate risk of death.
Standard treatments for AMI include aspirin, an antiplatelet drug that prevents blood clotting; supplemental oxygen to increase the heart’s oxygen supply; pain relievers like morphine for chest pain; beta-blockers to reduce the heart’s demand for oxygen, nitroglycerin to enhance blood flow to the heart muscle cells, an ACE inhibitor to lower blood pressure, and a statin drug to lower cholesterol. In addition to aspirin, heparin, an anticoagulant, may be administered to prevent the formation of additional blood clots.
Upon initial evaluation, patients are evaluated for reperfusion therapy, an approach to quickly restore blood flow to the damaged heart muscle to limit permanent damage.
Reperfusion is best done mechanically, where the patient has a catheter threaded through a large vessel toward the heart. Then, dye is injected to locate the blockage in the coronary artery. Once this is done, a percutaneous transluminal coronary angioplasty (PTCA) is performed. This procedure involves threading a different catheter with a small deflated balloon past the blockage and inflating the balloon to crush the clot and plaque. Most balloon catheters also have a wire mesh called a stent over the balloon. Once the balloon is inflated and unclogs the blocked artery, the stent remains in place to keep the artery open. In addition to aspirin, the patient might receive another antiplatelet medication, such as clopidogrel.
An alternate reperfusion method involves thrombolytic agents, which are clot-dissolving drugs. A thrombolytic agent, like tissue plasminogen activator (tPA), is used as a drug option when performing an angioplasty might be delayed due to the need for hospital transfer. Further medication may be necessary for a heart attack if the patient experiences complications such as severe cardiac arrhythmias, low blood pressure, or congestive heart failure.
Classification of Acute Myocardial Infarction
AMI classification encompasses various types with varying underlying causes. The specific type of AMI should be diagnosed promptly so appropriate treatment can begin.
The different types include:
- Type 1 (spontaneous MI))
- Type 2 (MI secondary to an ischemic imbalance)
- Type 3 (MI resulting in death due to unavailable biomarker values)
- Type 4a (MI associated with percutaneous coronary intervention [PCI])
- Type 4b (MI associated with in-stent thrombosis)
- Type 4c (MI associated with restenosis of coronary artery after previous percutaneous coronary intervention [PCI])
- Type 5 (MI associated with coronary artery bypass graft [CABG])
Mastering ICD-10-CM Coding for AMI
The ICD-10-CM codes for acute myocardial infarction reside within Chapter 9. Diseases of the Circulatory System (I00-I99), under Ischemic Heart Diseases (I20-I25). The codes for acute MI are broken down into Initial and Subsequent MI.
Initial Acute MI
An initial AMI is coded to I21, Acute myocardial infarction, when a patient has suffered an initial ST elevation (STEMI) or non-ST elevation (NSTEMI) myocardial infarction that is specified as acute or with a stated duration of 4 weeks (28 days) or less from the onset.
Initial AMI codes from category I21 include:
- I21.01, ST elevation (STEMI) myocardial infarction involving left main coronary artery
- I21.02, ST elevation (STEMI) myocardial infarction involving left anterior descending coronary artery
- I21.09, ST elevation (STEMI) myocardial infarction involving other coronary artery of anterior wall
- I21.11, ST elevation (STEMI) myocardial infarction involving right coronary artery
- I21.19, ST elevation (STEMI) myocardial infarction involving other coronary artery of inferior wall
- I21.21, ST elevation (STEMI) myocardial infarction involving left circumflex coronary artery
- I21.29, ST elevation (STEMI) myocardial infarction involving other sites
- I21.3, ST elevation (STEMI) myocardial infarction of unspecified site
- I21.4, Non-ST elevation (NSTEMI) myocardial infarction
- I21.9, Acute myocardial infarction, unspecified
- I21.A1, Myocardial infarction type 2
- I21.A9, Other type of myocardial infarction
Coding Guidelines Related to Initial MI
Based on the ICD-10-CM Official Guidelines for Coding and Reporting, keep the following in mind when coding from category I21:
- The ICD-10-CM codes for type 1 STEMI and NSTEMI identify the site, such as the anterolateral wall or true posterior wall.
- Codes I21.01-I21.3 are used for type 1 STEMI MI.
- If the provider documents acute MI but does not include the specific location, the appropriate code to assign is I21.3.
- Code I21.4 is used for type 1 NSTEMI MI and nontransmural MIs.
- Code I21.9 is used for unspecified AMI or unspecified type.
- Code I21.A1 is used for type 2 MI.
- Code I21.A9 is used for types 3, 4a, 4b, 4c, and 5 MI.
- If a type 1 NSTEMI evolves to STEMI, assign the STEMI code.
- If a type 1 STEMI converts to NSTEMI due to thrombolytic therapy, it is still coded as STEMI.
- For encounters occurring while the MI is equal to or less than 4 weeks old, including transfers to another acute or post-acute setting, and the MI meets the definition for “other diagnoses,” codes from category I21 may continue to be reported. For encounters after the 4-week timeframe and the patient is still receiving care related to the MI, the appropriate aftercare code should be assigned instead of a code from I21. Old or healed MIs not requiring further care should be coded to I25.2, Old myocardial infarction.
- If an AMI is documented as nontrasmural or subendocardial, but the site is provided, it is still coded as a subendocardial AMI.
Subsequent Acute MI
A subsequent AMI is coded to I22, Subsequent ST elevation (STEMI) and non-ST elevation (NSTEMI) myocardial infarction, when a patient has suffered a type 1 or unspecied AMI and has a new AMI within the 4-week timeframe (28 days) of the initial AMI. A code from category I22 must be used in conjunction with a code from category I21. The sequencing of the I22 and I21 codes depends on the circumstances of the encounter. “
Subsequent AMI codes from category I22 include:
- I22.0, Subsequent STEMI of anterior wall
- I22.1, Subsequent STEMI of inferior wall
- I22.2, Subsequent non-ST elevation (NSTEMI) myocardial infarction
- I22.8, Subsequent STEMI of other sites
- I22.9, Subsequent STEMI of unspecified site
Coding Guidelines Related to Subsequent MI
Other coding guidelines to keep in mind when coding from category I22:
- Do not assign code I22 for subsequent myocardial infarctions other than type 1 or unspecified.
- For subsequent type 2 AMI, assign only code I21.A1.
- For subsequent type 4 or type 5 AMI, assign only code I21.A9.
- If a subsequent myocardial infarction of one type occurs within 4 weeks of a myocardial infarction of a different type, assign the appropriate codes from category I21 to identify each type. Do not assign a code from I22. Codes from category I22 should only be assigned if both the initial and subsequent myocardial infarctions are type 1 or unspecified.
Before making your final code selection from categories I21 and I22, review the “Includes,” “Excludes,” “Code First,” “Code Also,” and “Use additional” notes.
Acute myocardial infarction coding demands accuracy, insight, and adherence to the coding guidelines. Be sure to abstract the pertinent information from the medical record relative to the site of the AMI, arteries affected, whether the AMI is initial or subsequent, and the type of AMI. Finally, read all the instructional notes provided, as they are crucial to correct coding.