This is the Cath PCI case scenario for April 2025, where we will be reviewing sequence number 9001, intra-post-procedure events, when capturing MI as an event. A 70-year-old male arrived in the emergency department with intermittent angina and shortness of breath on exertion. ECGN arrival was performed and labs were obtained. The patient was diagnosed with NSTEMI and admitted for a cath procedure that was scheduled for the following day. An 80% stenosis to the mid-LAD was found and PCI was performed successfully. The patient was then transferred to recovery. While in cath lab holding, the patient complained of persistent angina. A STAT ECG was performed and ST elevations were found on the post-procedure ECG. IV nitroglycerin drip was started and the patient immediately returned to the cath lab. On imaging, the distal LAD was found to have an occlusion due to new thrombus formation. Successful thrombectomy was performed with stent placement to the distal LAD without any further complications. And the patient was admitted to the ICU. Our question is, how is myocardial infarction coded in sequence 9001 intra-post-procedure events for the first cath lab visit? Number one, no. Or number two, yes. Please take a few moments to review the documentation before making your final selection. And the answer to code myocardial infarction is number two, yes, for sequence 9001 intra-post-procedure events. Let's first look at the data definition for MI as an intra-post-procedure event for sequence 9001. Located in the V5 data dictionary supplement with pending data element updates, myocardial infarction coding instructions for sequence 9001 are to capture whether the patient experienced a new occurrence of biomarker-positive MI, at least one determination of biomarkers obtained no sooner than six hours after the procedure, preferably within the interval of 6 to 24 hours post-procedure. You will see in the notes section the following. Code yes when new Q waves are present with absent, incomplete, or inconclusive biomarkers. Or code yes when biomarkers are not obtained in the setting of post-PCI acute MI. The registry has agreed to provide an advanced coding directive for coding yes when biomarkers are not obtained in the setting of post-PCI acute MI to enhance clarification during the abstraction process. When myocardial infarction is identified as an intra- or post-procedure event in the absence of biomarkers, myocardial infarction is coded yes whenever there is a new obstruction that results in new patient symptoms of ischemia and or ST elevation that without treatment would result in loss of viable myocardium or new regional wall motion abnormality. An example of this is when a cath procedure is in progress and there is a new plaque shift, thrombus, dissection, et cetera, that was not present at the start and requires immediate intervention as with a PCI in progress for a mid-LED lesion and plaque shift occludes the first diagonal, for example. The new additional coding directive, number 25638, can be located on the resource section of the NCDR website. Now, let's review the scenario and how we have applied the new additional coding directive. The patient presented to the cath lab with an NSTEMI indication and received a stent to the mid-LED. The procedure was successfully performed without complications and the patient was brought to recovery. Following the procedure while in recovery, the patient complained of angina and was found to have ST elevations on ECG. The patient was brought back to the cath lab and new thrombus to the distal LED was found that was not present during the initial cath lab procedure. Without bringing the patient back to the cath lab to perform a thrombectomy and stent placement to the distal LED, this would have resulted in loss of viable myocardium or new regional wall motion abnormality. Therefore, in this scenario, MI is captured as an intra-post-procedure event as the coding criteria are met. For a bonus question, how is sequence 7400, indication for cath lab visit, and sequence 7825, PCI indication, for the second cath lab visit coded? Is it, number one, new onset angina less than or equal to two months for sequence 7400 and new onset angina less than or equal to two months for sequence 7825? Is it, number two, worsening angina for sequence 7400 and other for sequence 7825? Or number three, ACS less than or equal to 24 hours and worsening angina for sequence 7400 and immediate PCI for STEMI for sequence 7825? Here's the documentation for reviewing sequence 7400 and 7825 using the V5 Data Dictionary Supplement. And the answer is number three. The coding guidance when a patient's original presentation for a diagnostic cath is not treated and the patient returns for a PCI in the same episode of care, and the indications for capturing sequence 7400 as well as their symptom assessment in sequence 7405 would continue to be applicable and support coding. However, once an intervention is performed, CABG or PCI, and the patient returns to the cath lab in the same episode of care, or a patient is discharged, please only capture new symptoms, conditions, if and when they return for a new lab visit. Per the coding instruction sequence 7400, cath lab indication is a select all data element. Therefore, as the patient had new acute ischemic symptoms with new ST elevation after PCI, that ACS less than or equal to 24 hours and worsening angina are coded in sequence 7400. Additionally, sequence 7825 is a single selection with a target value as the highest value at the start of the current procedure that most often correlates to information captured in sequence 7400 as they are related. In the given scenario, as the patient returned immediately to the cath lab where PCI was performed emergently and without delay after new STEMI diagnosis, then immediate PCI for acute STEMI is coded for sequence number 7825. For another bonus question, let's review a new scenario where we have the following documentation. A 72-year-old female presented for an elective cath in stable condition. Following the diagnostic cath, 75% stenosis to the proximal RCA was found and PCI performed to the single lesion. Following balloon inflation, the patient experienced chest pain with ST elevation. Upon deflation of the balloon, the patient's chest pain symptoms subsided and ST elevations on the cardiac monitor resolved. Stent placement to the proximal RCA was successful without further complications and symptoms of ischemia, and the patient was sent to recovery in stable condition. How is myocardial infarction coded in sequence 9001 intra-post-procedure events for the first cath lab visit? Number one, no. Or number two, yes. Here's the documentation for your review. The answer is number one, no. We're coding for MI for sequence 9001 intra-post-procedure events. Let's review the documentation. The patient presented for an elective PCI in stable condition. During balloon inflation to the 75% proximal RCA lesion, the patient complained of chest pain with ST elevation. Following angioplasty, the patient's chest pain symptoms and ST elevation on the cardiac monitor resolved. Stent placement to the proximal RCA was successful without further complications. For the purpose of the registry, when the patient has chest pain with ST elevations during device inflation and the ischemic changes are not from a new obstruction due to a new plaque shift, thrombus, dissection, et cetera, then MI is not captured as an intra-post-procedure event. Instead, the ischemic changes and ST elevation are considered transient due to diminished coronary blood flow during balloon inflation. Thank you for viewing the CAF PCI registry monthly case scenario for April of 2025, where we discuss sequence 9001 intra-post-procedure events for myocardial infarction.

PCI Registry

cardiac rehabilitation

medical rationale

patient care quality

documentation

NSTEMI

PCI

thrombectomy

STEMI

ischemic symptoms

myocardial infarction

coding guidelines