4th Universal Definition of MI

CDI Implications

ACDIS Radio – August 29, 2018

James S. Kennedy, MD, CCS, CDIP

President and Chief Medical Officer
CDIMD – Physician Champions
Smyrna, Tennessee
jkennedy@cdimd.com – (615) 479-7021

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Disclosures

• This presentation is designed to provide accurate and authoritative

information in regard to the subject matter covered. The information includes
both reporting and interpretation of materials in various publications, as well
as interpretation of policies of various organizations. This information is
subject to individual interpretation and to changes over time.
– VP-MA Health Solutions, dba CDIMD, HCPro, ACDIS, the individual speakers, and all
affiliated entities do not warrant that the written or oral opinions expressed in this lecture
apply to every situation. Prior to implementing any of the suggestions discussed at this
meeting, the attendee is advised to seek counsel from his or her compliance officer or
their legal counsel.
– CDIMD, HCPro, ACDIS, the individual speakers, and all affiliated entities support accurate
coding of every clinical circumstance based upon physician documentation, recognize the
role and responsibility of treating physicians to utilize language they deem appropriate to
their circumstances, and support compliance to all local, state, and federal laws.

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Learning Objectives

• Discuss the new 4th Universal Definition of Acute

Myocardial Infarction and its impact on CDI and
coding practices
• Advocate solutions that promote clinical validity
and coding compliance

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4th Universal Definition
Now Available

http://www.tinyurl.com/2018UDMI
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2018 4th UDMI
New Concepts

• Differentiation of myocardial infarction from myocardial injury.

• Highlighting peri-procedural myocardial injury after cardiac
and noncardiac procedures as discrete from myocardial
infarction.
• Consideration of electrical remodeling (cardiac memory) in
assessing repolarization abnormalities with tachyarrhythmia,
pacing, and rate-related conduction disturbances.
• Use of cardiovascular magnetic resonance to define the
etiology of myocardial injury.
• Use of computed tomographic coronary angiography in
suspected myocardial infarction.

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2018 4th UDMI
Definition of Myocardial Injury

• The term myocardial injury should be used when there

is evidence of elevated cardiac troponin values (cTn)
with at least one value above the 99th percentile upper
reference limit (URL). The myocardial injury is
considered acute if there is a rise and/or fall of cTn
values.
– What many physicians label as “troponin leak”,
“troponinemia”
– In some circumstances, “demand ischemia” without
elaborating as to if it is a myocardial infarction or
nonischemic myocardial necrosis is used

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Myocardial Injury vs.
Myocardial Infarction

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Criteria for Type 1, 2, 3
Acute Myocardial Infarction

• The term acute myocardial infarction should be used when ALL

THREE OF THE FOLLOWING APPLY:
1. Acute myocardial injury (troponin must be elevated)
2. Detection of a rise and/or fall of cTn values with at least one value
above the 99th percentile URL, AND
3. Clinical evidence of acute myocardial ischaemia withat least
one of the following:
• Symptoms of myocardial ischaemia;
• New ischaemic ECG changes;
• Development of pathological Q waves;
• Imaging evidence of new loss of viable myocardium or new regional
wall motion abnormality in a pattern consistent with an ischaemic
aetiology;
• Identification of a coronary thrombus by angiography or autopsy
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Criteria for Type 1
Acute Myocardial Infarction

• Acute myocardial injury +

• Symptoms of myocardial
ischaemia;
– New ischaemic ECG changes;
– Development of pathological Q
waves;
– Imaging evidence of new loss of
viable myocardium or new
regional wall motion abnormality
Atherosclerotic plaque in a pattern consistent with an
disruption with ischaemic aetiology;
thrombosis – Identification of a coronary
thrombus by angiography or
autopsy
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Criteria for Type 2
Acute Myocardial Infarction

• Acute myocardial injury +

• Symptoms of myocardial
ischaemia;
– New ischaemic ECG changes;
– Development of pathological Q waves;
– Imaging evidence of new loss of
viable myocardium or new regional
wall motion abnormality in a pattern
consistent with an ischaemic
aetiology;
– Identification of a coronary thrombus
by angiography or autopsy
• No evidence of type 1, 3, 4, or 5
mechanism
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Type 2 MI Mechanisms

Myocardial injury related to acute myocardial ischaemia

because of oxygen supply/demand imbalance

• Reduced myocardial • Increased myocardial

perfusion, e.g.
oxygen demand, e.g.
– Coronary artery spasm,
microvascular dysfunction – Sustained
– Coronary embolism tachyarrhythmia
– Coronary artery dissection – Severe hypertension
– Sustained bradyarrhythmia NOTE:with or without
Demand left
ischemia
– Hypotension or shock
aloneventricular
should havehypertrophy
a normal
– Respiratory failure
– Severe anaemia troponin; not a “troponin
leak”.
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What Troponin Elevations are NOT
Acute Myocardial Infraction
• Cardiac conditions, e.g.
– Heart failure
– Myocarditis
– Cardiomyopathy (any type)
– Takotsubo syndrome
– Coronary revascularization
procedure
– Cardiac procedure other
than revascularization
– Catheter ablation
– Defibrillator shocks
– Cardiac contusion
4th UDMI encourages the documentation of “acute myocardial injury”
• Systemic conditions, e.g.
– Sepsis, infectious disease
– Chronic kidney disease
– Stroke, subarachnoid
haemorrhage
– Pulmonary embolism,
pulmonary hypertension
– Infiltrative diseases, e.g.
amyloidosis, sarcoidosis
– Chemotherapeutic agents
– Critically ill patients
– Strenuous exercise
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ICD-10-CM Index Challenges
Myocardial Injury

INJURY
• - heart S26.90
• ICD-10-CM
• - - with hemopericardium S26.00 Index
– - - - contusion S26.01
– - - - laceration (mild) S26.020 classifies
• - - - - moderate S26.021
• - - - - major S26.022 “myocardial
– - - - specified type NEC S26.09
• - - contusion S26.91 injury” only
•
•
- - laceration S26.92 as traumatic
- - specified type NEC S26.99
• - - without hemopericardium S26.10 in nature
– - - - contusion S26.11
– - - - laceration S26.12
• - - - specified type NEC S26.19

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Code Title Suggested by Index
Conflicting with Clinical Diagnoses

(If the index is confusing), A basic rule of coding is that

further research is done if the title of the code suggested by
the index clearly does not identify the condition correctly.
– Coding Clinic, Second Quarter 1991 Page: 20
– Coding Clinic, Third Quarter 2004 Page: 5 to 6
– Coding Clinic, First Quarter 2013 Pages: 13-14
Possible options:
• Consider myocardial injury as integral to the linked heart disease
(e.g. myocarditis, Takotsubo cardiomyopathy, heart trauma)
• I52, Other heart disorders in diseases classified elsewhere, if the
linked underlying cause is not cardiac in nature (cannot be PDx)
• I51.89 Other ill-defined heart diseases if no cause is given
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Myocardial Injury w/o M. Infarction
Coding Clinic, 1st Quarter, 1992, pp 9-10

Question: - The physician has documented acute myocardial injury as a

diagnosis.
• There is no evidence of myocardial infarction, based on cardiac enzymes, and
no electrocardiogram changes noted other than acute myocardial injury. Should
this be coded to 410.90-410.92, Acute myocardial infarction, unspecified site?
Answer: No, assign code 411.89, Other acute and subacute forms of ischemic
heart disease.
• The Alphabetical Index is silent under acute myocardial injury and the entry
under acute heart injury implies only trauma (external injury) to the heart, codes
861.00-861.13.
– It is inappropriate to extrapolate "acute myocardial injury" to infarction; in fact, the
term acute myocardial injury is most commonly synonymous with acute myocardial
ischemia.
• Here, the index does differentiate between acute myocardial ischemia with and
without infarction and should be followed in this situation.
DR. KENNEDY BELIEVES THAT THIS ADVICE IS INVALID, ESPECIALLY WITH 4TH UDMI
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Type 4 and 5 MIs

• Percutaneous coronary intervention (PCI)

related MI is termed type 4a MI.
• Coronary artery bypass grafting (CABG) related
MI is termed type 5 MI.
• Other types of 4 MI include
– Type 4b MI stent thrombosis
– Type 4c MI restenosis
• Criteria for 4b and 4c use type 1 MI criteria
• Criteria for Type 4a and Type 5 MI is on next slide

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Type 4A and Type 5 MI Criteria

• Coronary procedure-related MI ≤ 48 hours after the index procedure is arbitrarily

defined by an elevation of cTn values > 5 times for type 4a MI and > 10 times for type
5 MI of the 99th percentile URL in patients with normal baseline values.
– Patients with elevated pre-procedural cTn values, in whom the pre-procedural cTn level are
stable (≤ 20% variation) or falling, must meet the criteria for a > 5 or > 10 fold increase and
manifest a change from the baseline value of > 20%.
– In addition with at least one of the following:
• New ischaemic ECG changes (this criterion is related to type 4a MI only);
• Development of new pathological Q waves;
• Imaging evidence of loss of viable myocardium that is presumed to be new and in a
pattern consistent with an ischaemic aetiology;
• Angiographic findings consistent with a procedural flow-limiting complication such as
coronary dissection, occlusion of a major epicardial artery or graft, side-branch
occlusion-thrombus, disruption of collateral flow or distal embolization.
• Isolated development of new pathological Q waves meets the type 4a MI or type 5 MI
criteria with either revascularization procedure if cTn values are elevated and rising but
less than the pre-specified thresholds for PCI and CABG.
• Post-mortem demonstration of a procedure-related thrombus meets the type 4a MI
criteria or type 4b MI criteria if associated with a stent.
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Other Updated Concepts

• Type 1 myocardial infarction: Emphasis on the causal relationship of

plaque disruption with coronary athero-thrombosis; new Figure 3.
• Type 2 myocardial infarction:
– Settings with oxygen demand and supply imbalance unrelated to acute
coronary athero-thrombosis; new Figures 4 and 5.
– Relevance of presence or absence of coronary artery disease to
prognosis and therapy.
– Differentiation of myocardial injury from type 2 myocardial infarction;
new Figure 6.
• Type 3 myocardial infarction: Clarify why type 3 myocardial infarction is a
useful category to differentiate from sudden cardiac death.
• Types 4–5 myocardial infarction: Emphasis on distinction between
procedure-related myocardial injury and procedure-related myocardial
infarction.

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Other Updated Concepts

• Cardiac troponin: Analytical issues for cardiac troponins; new Figure 7.

• Emphasis on the benefits of high-sensitivity cardiac troponin assays.
• Considerations relevant to the use of rapid rule-out and rule-in protocols for
myocardial injury and myocardial infarction.
• Issues related to specific diagnostic change (’delta’) criteria for the use of
cardiac troponins to detect or exclude acute myocardial injury.
• Consideration of new non-rate-related right bundle branch block with specific
repolarization patterns.
• ST-segment elevation in lead aVR with specific repolarization patterns, as a
STEMI equivalent.
• ECG detection of myocardial ischaemia in patients with an implantable
cardiac defibrillator or a pacemaker.
• Enhanced role of imaging including cardiac magnetic resonance imaging for
the diagnosis of myocardial infarction; new Figure 8.

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New Sections

• Takotsubo syndrome.
• MINOCA (and INOCA)
– Myocardial infarction w/non-obstructive coronary
arteries (<50% stenosis)
– Ischemia w/non-obstructive coronary arteries
• Chronic kidney disease (including ESRD).
• Atrial fibrillation.
• Regulatory perspective on myocardial infarction.
• Silent or unrecognized myocardial infarction.
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Thank you.

Questions?

James S. Kennedy MD
(615) 479-7021
jkennedy@cdimd.com

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