Q&A Question For Discussion

[Sparky]

If a patient were discharged from the hospital with a diagnosis of probable myocardial infarction without a history of MI in the past, how would we as coders document for this stay?

 

[Alicia Scott]

This is tricky. You can not use 412 unless it has been more then 8 wks. If the dx states probable MI then you can only code the side effects. Just a note with inpatient though. The rules are different then outpatient. I doubt that in real life a person would be given a dx of probable MI on d/c .They would give a definitive dx.

 

[Sparky]

Alicia, thank you. Then in real life the dx would be MI? Whether you have a time-frame listed or not?

 

[Laureen]

For non-inpatient coding we don't code "probable" codes only confirmed. So you just code the signs and symptoms in the absence of a definitive diagnosis or until one is confirmed.

 

[Alicia Scott]

You can't code a probable MI. I need to read the guidelines again on dates. For Medicare Advantage coding that I do I can not code 412 unless it has been more then 8 wks or documented as old. Now keep in mind you can NOT code this in "real life" without that time frame. I am saying that you will not get a person released from the hospital with a dx of probable MI. They are going to keep that person there until they know if they have had one or not. All they need to do is run and EKG. That will tell them if an MI occurred.

 

[Sparky]

Thank you. I will make a note of that in my book.