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Q&A: Query for "Type 2 injury"

CDI Strategies, January 21, 2016

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Q: I was reviewing a case with one of our CDI specialists this morning. Briefly, the following clinical indicators documented in the chart are elevated cardiac enzymes, shock, and demand ischemia. Cardiology documented “elevated cardiac enzymes in setting of shock representing a Type 2 injury.” Also documented in another note is “demand ischemia.”

The physician did not document the words “Type 2 myocardial infarction (MI).” Is the wording “Type 2 injury” enough to support a code for MI? Our physician advisor thinks Type 2 MI should code to a NSTEMI. Should we query in this instance and, if so, what should we include in the query?

A: This is a great question and one that many CDI specialists struggle with. The issue is inconsistency with the use of Type 2 MI. A Type 2 MI is one that is secondary to ischemia due to either increased oxygen demand or decreased supply. Your physician advisor is correct that if the wording Type 2 MI was used, an MI should be coded. But we must remember the physician needs to identify the MI as either an NSTEMI or STEMI. If no differentiation is provided by the physician, the code will default to an assignment for STEMI.

You are also correct in identifying that the wording “Type 2 injury” is vague and requires clarification. This could mean an MI but also could be interpreted as demand ischemia. With the documentation you have provided in your question, a query is needed. Consider a query similar to the following:

Dear Dr. Heart,

You documented the diagnosis of “Type 2 injury” for this patient admitted with elevated cardiac enzymes in the presence of shock.  (List any other clinical indicators-complaints of chest pain, lab values etc. and treatments provided). Please clarify the meaning of Type 2 injury?

1. Demand ischemia
2. Type 2 myocardial infarction (NSTEMI)
3. Unable to determine
4. Other__________ 

Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, and CDI Education Director at HCPro in Danvers, Massachusetts, answered this question. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps visit www.hcprobootcamps.com/courses/10040/overview.

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