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ICD-10 Coding for ST-Elevation Myocardial Infarction(I21.01, I21.02, I21.11)

Complete ICD-10-CM coding and documentation guide for ST-Elevation Myocardial Infarction. Includes clinical validation requirements, documentation requirements, and coding pitfalls.

Also known as:

STEMIAcute Myocardial Infarction with ST Elevation

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Related ICD-10 Code Ranges

Complete code families applicable to ST-Elevation Myocardial Infarction

I21.0-I21.3Primary Range

Acute myocardial infarction with ST elevation

This range includes codes for STEMI based on the location of the infarction.

Code Comparison: When to Use Each Code

Compare key differences between these codes to ensure accurate selection

CodeDescriptionWhen to UseKey Documentation
I21.01STEMI involving left main coronary arteryUse when STEMI involves the left main coronary artery.
  • ST elevation in aVR
  • Coronary angiography confirmation
I21.02STEMI involving left anterior descending arteryUse when STEMI involves the left anterior descending artery.
  • ST elevation in leads V1-V4
  • Troponin elevation
I21.11STEMI involving right coronary arteryUse when STEMI involves the right coronary artery.
  • ST elevation in leads II, III, aVF
  • Reciprocal changes in I/aVL

Clinical Decision Support

Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.

Key Information: ICD-10 code for STEMI

Essential facts and insights about ST-Elevation Myocardial Infarction

The ICD-10 codes for STEMI range from I21.0 to I21.3, based on the infarction location.

Primary ICD-10-CM Codes for stemi

I21.01
STEMI involving left main coronary artery
Billable Code

Decision Criteria

clinical Criteria

  • Presence of ST elevation in aVR with diffuse ST depression

Applicable To

  • ST elevation in aVR with diffuse ST depression

Excludes

Clinical Validation Requirements

  • ST elevation in aVR
  • Coronary angiography confirmation

Code-Specific Risks

  • Misclassification if location is not specified

Coding Notes

  • Ensure documentation specifies the coronary artery involved.
View Full Code Details

Ancillary Codes

Additional codes that should be used in conjunction with the main diagnosis codes when applicable.

Hypertension

I10
Use if patient has a history of hypertension.

Type 2 diabetes mellitus

E11
Use if patient has a history of diabetes.

Cardiogenic shock

R57.0
Use if patient presents with cardiogenic shock.

Differential Codes

Alternative codes to consider when ruling out similar conditions to the primary diagnosis.

NSTEMI

I21.4
NSTEMI does not show ST elevation on ECG.

Documentation & Coding Risks

Avoid these common documentation and coding issues when documenting ST-Elevation Myocardial Infarction to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code I21.01.

Impact

Clinical: Lack of specificity can lead to inappropriate treatment., Regulatory: Non-compliance with documentation standards., Financial: Potential for incorrect billing and reimbursement.

Mitigation Strategy

Educate clinicians on the importance of specifying MI type, Use templates that prompt for detailed documentation

Impact

Reimbursement: May lead to lower DRG assignment and reimbursement., Compliance: Non-compliance with ICD-10 specificity requirements., Data Quality: Reduces the accuracy of clinical data.

Mitigation Strategy

Query for specific artery involvement to use the correct code.

Impact

Reimbursement: Incorrect coding can affect DRG and HCC scores., Compliance: Risk of audit failure due to incorrect MI classification., Data Quality: Impacts clinical data integrity and patient records.

Mitigation Strategy

Ensure documentation specifies the type of MI and underlying cause.

Impact

Audits often find issues with the specificity of MI coding, particularly in distinguishing STEMI from NSTEMI.

Mitigation Strategy

Implement regular training sessions on MI coding and documentation.

Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.

Frequently Asked Questions

Common questions about ICD-10 coding for ST-Elevation Myocardial Infarction, with expert answers to help guide accurate code selection and documentation.

Documentation Templates for ST-Elevation Myocardial Infarction

Use these documentation templates to ensure complete and accurate documentation for ST-Elevation Myocardial Infarction. These templates include all required elements for proper coding and billing.

Emergency Department Note

Specialty: Emergency Medicine

Required Elements

  • HPI
  • ECG findings
  • Troponin levels
  • Impression
  • Plan

Example Documentation

**HPI:** 58M with 45min crushing substernal chest pain radiating to jaw **ECG:** ST elevation 3mm in II, III, aVF; reciprocal ST depression in V1-V3 **Labs:** Troponin I 15.2 ng/mL (0-0.04) **Impression:** Acute inferior STEMI (I21.11) involving right coronary artery **Plan:** Emergent PCI

Examples: Poor vs. Good Documentation

Poor Documentation Example
Heart attack confirmed
Good Documentation Example
Acute anterior STEMI (I21.02) with ST elevation in V2-V4, troponin T 1.8 ng/mL (ref <0.1)
Explanation
The good example specifies the type of MI, location, and includes diagnostic criteria.

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