Chest Pain-MI v3.1 Education-Diagnosis

Video Transcription

This new section, Diagnosis, includes the patient type, STEMI setting, admitting diagnosis, and STEMI non-thrombotic mechanisms present.  Sequence 15478, Admitting Diagnosis, seeks to capture the first or original admitting diagnosis documented prior to the in-hospital STEMI between arrival at the first facility  and discharge. In-hospital admitting diagnosis is coded as medical cardiac, medical non-cardiac, surgical cardiovascular, or surgical non-cardiovascular.  We've provided examples for a clearer understanding, however, the admitting diagnoses are not limited to the following examples.  Cardiac medical may include diagnoses such as heart failure and or non-STEMI. Medical non-cardiac may include diagnoses such as GI bleed and or sepsis.  Surgical cardiovascular may include diagnoses such as valve replacement and or CABG. Surgical non-cardiovascular may include diagnoses such as hip replacement and or hysterectomy.  Sequence 15599, Non-Thrombotic Mechanism, seeks to capture any of the pathophysiological mechanisms attributed to a non-atherosclerotic MI that are present when STEMI is the patient  type. Sequence 15599, Non-Thrombotic Mechanism, coding instructions. If STEMI patient type, indicate any of the pathophysiological mechanisms attributed to  a non-atherosclerotic MI are present. To warrant choosing a selection, clear documentation must be in the current medical record to select  one of the following causes, coronary embolism, coronary vasospasm, spontaneous coronary artery  dissection or SCAD, Takotsubo cardiomyopathy, or other cause identified as a type 2 MI. To select other, if SCAD, coronary embolism, coronary vasospasm, or Takotsubo cardiomyopathy  is not diagnosed as the mechanism of injury associated with the MI and any of the following terms are documented in the medical record, type 2 or supply demand, the target value  is the value on discharge.

Video Summary

The Diagnosis section of the video discusses capturing patient type, STEMI setting, admitting and non-thrombotic mechanisms for STEMI cases. Admitting Diagnosis (Sequence 15478) focuses on the original diagnosis prior to in-hospital STEMI, coded as cardiac or non-cardiac. Examples include heart failure for cardiac and GI bleed for non-cardiac. Non-Thrombotic Mechanism (Sequence 15599) aims to identify pathophysiological mechanisms for non-atherosclerotic MI in STEMI patients, including coronary embolism, vasospasm, SCAD, Takotsubo cardiomyopathy, or other causes like type 2 MI. Clear documentation in the medical record is essential for selection, with a focus on identifying specific mechanisms for accurate coding.

Keywords

Registry Site Manager

Administration tab

Site User Administration

access control

user privileges

patient type

STEMI setting

admitting diagnosis

non-thrombotic mechanisms

pathophysiological mechanisms