Q&A: Physician documentation of troponin leak
CDI Strategies, May 14, 2008
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Q: At my facility we have a problem with providers documenting 'troponin leak'. I have spoken to one cardiologist who states all troponin elevations above .04 should be stated as an MI even if they lack acute coronary syndrome signs and symptoms. He presented a paper from the American College of Cardiology with the clinical classification of the different types of myocardial infarction (MI) (www.cardiosource.com) and he feels if the troponins are positive and the cause is related to sepsis, tachycardia, ect., it is a type 2 MI.
I spoke with a second cardiologist and an internist who disagrees with this viewpoint. They feel that a 'troponin leak' or elevated troponin should be stated as due to myocardial ischemia sec to sepsis, tachycardia etc. My coder here states that with some DRGs, if there is no history of chronic ischemia, myocardial ischemia may be a CC, but that for the most part myocardial ischemia will not be coded so there isn’t much incentive to query for it when we see 'troponin leak'. I think it always better to clarify documentation. What information do you have or can you find regarding this issue?
A: I recommend that you look at the October 2007 universal definition of acute MI from the American Heart Association, as well as the heart associations of many other countries. They define five clinical scenarios regarding acute MI, the first of which is represented by the classical rupture of a coronary plaque, and the second of which may be related to supply and demand issues regardless of the presence of disease of the coronaries.
If there is a changing pattern of troponin levels in face of increased demand, as in sepsis or tachyarrhythmias, the unanimous advice is to call it a non-ST-elevation MI due to whatever the inciting factor may be.
(Robert S. Gold, MD, CEO of DCBA, Inc., in Atlanta, GA, answered this question. Contact Dr. Gold at DCBAInc@cs.com)
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