Acute MI – Another Evolution in TerminologyRussell Firman MD, FACEP, CHCQM, PHYS-ADV The American College of Cardiology released a new consensus statement, “Expert Consensus Decision Pathway on the Evaluation and Disposition of Acute Chest Pain in the Emergency Department: A Report of the American College of Cardiology Solution Set Oversight Committee. (1) The most important content for Physician Advisors is the incorporation of the new “STEMI equivalents” for emergent revascularization. These EKG findings that do not include elevation of the ST segment of the EKG include De Winter T Waves, Hyperacute T waves, Posterior MI, and LBBB with Smith – modified Sgarbossa Criteria. The old STEMI paradigm alone does not capture all acute MI’s that are occluding or severely compromising flow to the coronary vessel. (2) The term acute “occlusive myocardial infarction” includes both “STEMI” and “STEMI equivalent” EKG findings for emergent revascularization. The guidelines state: “In the absences of ischemic ST – elevation, the EKG should be examined for other changes that have been associated with coronary artery occlusion.; when present, these should prompt evaluation for emergency coronary angiography.” The consensus statement recommends STEMI and STEMI equivalents be managed per the 2013 ACCF/ AHA STEMI guidelines. More patients (STEMI equivalents) will be eligible for emergent cardiac catheterization. What is in this for the Physician Advisor you might wonder? It is amazing how quickly these patients go home, sometimes before a midnight, or even after only one is crossed. An inpatient only procedure (IPOL) is an exclusion for a Medicare part A short stay. Most Medicare Advantage (MA) plans allow an IPOL procedure to be an exception in their short stay or observation policies. So, let’s review the two inpatient only codes associated with the coronary revascularization. Inpatient only codes description: CPT 92941 - Percutaneous transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction, coronary artery or coronary artery bypass graft, any combination of intracoronary stent, atherectomy and angioplasty, including aspiration thrombectomy when performed, single vessel HCPCS code C9606 - Percutaneous transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction, coronary artery or coronary artery bypass graft, any combination of drug-eluting intracoronary stent, atherectomy and angioplasty, including aspiration thrombectomy when performed, single vessel (This code is a facility code, not to be used by physicians. For facility coding, 92941 is used if there is a non-drug eluting stent used and C9606 used for a drug-eluting stent. Although both of these are inpatient only for Medicare and would be denied on an outpatient claim, they may be needed for other payers and there are equivalent pairs for stenting in the non-MI setting which is often performed and billed outpatient.) The new STEMI equivalent EKG findings may erroneously be called “NSTEMI” by people unfamiliar with the new guidelines. Our role should be to educate that the more appropriate terms are “STEMI equivalent EKG findings” or “(acute) occlusive MI.” Acute Occlusive MI includes all STEMI’s and all the new STEMI equivalent EKG findings and even better aligns with the CPT code definition. A true “NSTEMI” now should only include those EKG patterns that do not include a STEMI or any of the new STEMI equivalent EKG findings mentioned in the new guidelines. A true NSTEMI usually waits to undergo cardiac intervention after a delay for stabilization, usually the next day on an urgent basis. The CPT 92941 definition should not be used with a NSTEMI when the treatment of an acute occlusion does not require an immediate intervention. Do not miss the opportunity to capture the IPOL procedure for your patients who are undergoing emergent catheterization for the new STEMI equivalents. Make sure your coders and case managers have access to this information as well. An appropriate CPT code of 92941 without an Inpatient order is a lost opportunity and may not be reimbursed. On the other hand, an unknowing provider may call a “STEMI equivalent” a NSTEMI, thereby resulting in an erroneous code assignment and another lost opportunity for an IPOL procdure. Keep an eye out for a future Observation Committee Town Hall where we will review this case with a few twists, and some other great examples of short stay Inpatient Only Procedures and other topics made for you to add value to your team. Dr Firman is Lead Physician Advisor at St. Joseph’s Health in Syracuse, NY |