by Richard D. Pinson, MD, FACP, CCS
Q: A patient with a personal medical history of congestive heart failure (CHF), myocardial infarction (MI), coronary artery disease with three stents, ischemic cardiomyopathy, and chronic kidney disease (CKD) is admitted for acutely decompensated chronic systolic CHF. She had no chest pain or other ischemic symptoms. The initial troponin level was 0.26 (our lab reference range is <0.10) which slowly trended downward: 0.19, 0.15, 0.14. EKG reported ST and T-wave abnormality, consider inferolateral ischemia.
The attending physician spoke with Cardiology who believed the troponin elevation was likely due to a combination of CKD and “troponin leak” from cardiac strain due to CHF. The attending MD has documented Troponin I above reference range. No further testing is being done.
I was considering a query for Type 2 MI due to demand ischemia this patient did not have symptoms of ischemia. Should just be coded with R77.8 (Other specified abnormalities of plasma proteins) and not queried. Is it ever appropriate to query for demand ischemia alone?
A: I would not query at all. The Cardiologist has indicated that the troponin elevation is likely due to non-ischemic causes – a combination of CKD and “troponin leak” from cardiac strain due to CHF. Furthermore, as you noted, nothing is stated in the record to indicate symptoms of ischemia, the EKG report notwithstanding. I would not assign R77.8 since it’s a Chapter 18 symptom code, not to be coded when a definitive cause is identified, in this case, CHF and CKD. If the stable GFR were <30, I would query for CKD stage 4 or 5 (CCs).
Non-ischemic causes of troponin elevation may be cardiac or non-cardiac in origin. Common causes are CHF, tachyarrhythmia, myocarditis, cardiomyopathy, catheter ablation, defibrillation, cardiac contusion, and systemic causes such as CKD, sepsis, CVA/hemorrhage, pulmonary embolism or hypertension, chemotherapy, and infiltrative diseases (e.g., amyloidosis, sarcoidosis).
T2MI is commonly caused by coronary artery spasm, embolism, or dissection; sustained tachy- or brady-arrhythmia, severe anemia, hypotension, shock, or severe hypertension.
The Pinson & Tang CDI Pocket Guide provides specific standardized query templates for the most common medical conditions as well as instruction on how to modify the template to fit the particular circumstances of the case in question.
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About the Author
Dr. Richard Pinson, MD, FACP, CCS
Dr. Richard Pinson is a physician, educator, administrator, and healthcare consultant. He practiced Internal Medicine and Emergency Medicine in Tennessee for over 20 years having board certification in both. Dr. Pinson is a Fellow of the American College of Physicians and former Assistant Professor of Clinical Medicine at Vanderbilt, and has assisted hospitals as a physician consultant for the past ten years. Dr. Pinson’s personal understanding of the mindset of both doctors and managers allows him a unique vantage point from which to promote cooperation between physicians, hospital staff, and administrators toward achieving beneficial and practical changes.