H&P: 68 yr. old male admitted from home through the ED with complaints of SOB, cough, weakness, and chest pain. Diagnosed with sepsis due to left lung pneumonia, hypotension responsive to fluids, AKI, and elevated troponin.
PMH: CAD, HTN
Vitals: HR 118, RR 28, temp 39.4, BP 95/62, MAP 73 02 Sat 98% on RA
Labs: WBC 17 with segs 92%, troponin 118, BUN 32, Cr 1.45, GFR 48, lactic acid 3.4. Repeat labs in 24 hours show WBC 10, segs 88%, BUN 24, Cr 0.88, GFR 86, troponin 22, lactic acid 1.5.
Chest X-Ray: Left infiltrates indicative of pneumonia
PE: Rhonchi and rales bilaterally especially on left, cough, + sputum
Treatment: IV NS 1L fluid bolus, cardiology consult, serial cardiac markers
Meds Ordered: D51/2NS at 125 ml/hr, IV ceftriaxone and oral azithromycin, SQ Lovenox- home metoprolol held due to hypotension
Cardiology Consult: No EKG changes, mild chest pain, bp responsive to fluids. Diagnosis- elevated troponin, demand ischemia-hold on cath at this time, order Echo.
Echo: New regional wall motion abnormality in pattern consistent with an ischemic etiology, EF 55%
Discharge Summary: Patient admitted due to shortness of breath, productive cough, and weakness. Given IV fluids for hypotension and AKI with IV and oral antibiotics for sepsis and pneumonia. Final diagnosis: sepsis, pneumonia, AKI, hypotension, and elevated troponin with demand ischemia
Question: Are there query opportunities based on the scenario stated above?
Discussion: The patient exhibited the following risk factors and clinical indicators:
- Sepsis due to Pneumonia
- AKI
- Lactic Acid 3.4 with return to 1.5 following treatment
- History of CAD and HTN
- Troponin 118 (above 99% reference level for facility), cardiology consult, EKG without changes with documentation of demand ischemia
UASI Recommends:
- Query for Type 2 MI and etiology
- Query to link AKI as Sepsis associated Organ Dysfunction
- Query for Lactic Acidosis
Documentation without Clarification:
- Principal Diagnosis: Sepsis (A41.9)
- Secondary Diagnosis: Pneumonia (J18.9), AKI (N17.9), HTN (I10), CAD (I25.10)
- Working DRG: 871 Septicemia or Severe Sepsis without MV > 96 hours with MCC
- RW: 1.8722 GLMOS: 4.8 SOI/ROM: 2/2
Documentation with Clarification:
- Principal Diagnosis: Sepsis (A41.9)
- Secondary Diagnosis: Pneumonia (J18.9), AKI (N17.9), HTN (I10), CAD (I25.10), Type II MI (I21.A1) second MCC, Severe sepsis without septic shock (R65.20), Acidosis, (E87.2)
- Working DRG: 871 Septicemia or Severe Sepsis without MV > 96 hours with MCC
- RW: 1.8711 GLMOS: 4.8 SOI/ROM: 3/4
CDI Educational Tips:
The Forth Universal Definition of MI, released in 2018 by the Journal of the American College of Cardiology introduced the term ‘myocardial injury’ defined as an elevated troponin value above the 99th percentile upper reference limit. Acute myocardial injury is considered when there is both a rise and/or fall of the values.
- Type 1 MI includes STEMI, Q-wave, and NSTEMI with coronary thrombosis due to CAD. STEMI or Q-wave infarctions require immediate reperfusion therapy or percutaneous coronary intervention (PCI) and have self-evident EKG findings.
- Type 2 MI is diagnosed in the presence of elevated troponins primarily due to a supply/demand imbalance without coronary thrombosis i.e. not due to CAD and the presence of at least one of the following:
- Symptoms of acute myocardial ischemia
- New ischemic ECG changes
- Imagining evidence of new loss of viable myocardium, or new regional wall motion abnormality in a pattern consistent with an ischemic etiology
- Development of pathological Q waves (usually only when due to coronary embolism or dissection)
- Unstable angina is recognized by symptoms consistent with myocardial ischemia related to CAD, however without the presence of elevated troponins.
- Demand Ischemia was not specifically mentioned in the Fourth Universal Definition, however is generally recognized as symptoms consistent with myocardial ischemia primarily due to a ‘supply-demand mismatch’ (rather than CAD) without the presence of elevated troponins.
Query Tip: The term ‘demand ischemia’ is used arbitrarily in the presence of supply/demand circumstances both when the patient experiences myocardial injury i.e. elevated troponin and without the presence of myocardia injury. Consider a query for Type 2 MI when the diagnosis of demand ischemia has been documented and the patient demonstrates elevated troponin and meets diagnostic criteria.
| Diagnosis | CC/MCC Designation | SOI/ROM Designation |
| Demand Ischemia | CC | 2/2 |
| Type 2 MI | MCC | 2/4 |
- Review instructional code first underlying cause notation (I21.A1)
This is a short synopsis of a possible patient record and is not intended to be all inclusive. This is for educational purposes only and not intended to replace your institutional guidelines.