Ask Dr. Z

In the Case of the Month for May 2018 an acute MI was not documented. The EKG showed ST elevations, and patient was taken to the cath lab emergently, but neither of these proves an acute MI. Under “3.) LAD” it states that lesions of the LAD “seem to be the culprit for current presentation” (substernal chest discomfort and dyspnea only). Also, there was no thrombus in the LAD, which is often present in an acute MI. Although the case does meet the three criteria for use of 92941 as described in CPT Assistant Jan 2014, that article warns that conditions such as non-cardiac chest pain or unstable angina “do not fulfill the designation requirement of ‘during acute myocardial infarction,’ even if there is emergent activation of the catheterization laboratory.” Under these circumstances I question whether code I21.02 or the acute MI procedure code 92941/C9606 are appropriate. Is it okay to code an acute MI in the absence of physician documentation of an acute MI when the three criteria are met?