I have an interesting case needing your opinion.

Patient had knee replacement surgery and post surgery complained of chest pain. Tests revealed elevated troponins which physician classified as NSTEMI. Upon further diagnostic testing, it was revealed it was a Type 2 NSTEMI which medically means as explained to me elevated troponins due to imbalanced oxygen demand and supply, not due to plaque rupture and can be caused by arrhythmia, hypotension, sepsis, etc.

Therefore, hospital stay was coded as I21.4.

Patient came back to the clinic 27 days after initial diagnosis. Coder said that per coding guidelines, within 28 days the NSTEMI must be coded as such and must "follow" and be documented in the clinic post hospital follow up.

The doctor felt that since the NSTEMI is a Type 2 and not caused by CAD, he did not document the NSTEMI. His reason is that it was a transient diagnosis during the hospital stay and not an active diagnosis during office visit. His reluctance to mention NSTEMI is because he said if it is in the documentation, other providers might not understand the complexities of different types of NSTEMI and recommend the patient to have procedures that might harm the patient.

Coder came back insisting that we will be "flagged" and NSTEMI coding is strict. She attended one of your seminars and she wants to hear it from you. I attended several of your seminars and the gist is that as long as the physician is documenting it and able to defend his notes. Her suggestion is for the physician to go back and change his notes to suit the coding guidelines, which no physician would agree to in our group.

I understand that as coders we need to adhere to the coding guidelines but in the real world it is the patient’s wellness and welfare we need to prioritize when it comes down to documentation and communication.

Can somebody please explain to how not coding NSTEMI through all subsequent visits will be flagged. Our notes are very extensive and well supports the diagnosis, compared to other physicians in our small town.

Thanks!