Coding and Documentation
- Coding and Documentation
- Acute STEMI
- Presents within 12 hours or less of initial symptoms
- Late Presentation STEMI
- between 12 and 24 hours after symptom onset
- Diagnosis in note should be “Late presentation STEMI”
- If diagnosis has changed - change it in the note!
- STEMI → Late Presentation STEMI
- STEMI and Cardiac Arrest → just Cardiac Arrest
- STEMI → NSTEMI
- NSTEMI Type I vs Type II
- Document reason for not following GMT
- “BB held for hypotension and will be reevaluated at follow up appointment”
- “ACE/ARB held d/t…”
- “Cardiac rehab not appropriate b/c…”
- Reciprocal ∆ makes STE more specific for ischemia as the underlying etiology
- Q waves (with normal ST segments) = “old” MI
- Anterolateral STEMI
- Cause: Occlusion of the LAD
- Acute Inferior Posterior STEMI
- Tip: quick way is to turn your ECG upside → see the STE and Q waves in V1-V2
- Cause: Occlusion of the RCA (LCx) artery