Breaking Down the Complex Requirements for ICD-10-CM Hospice Coding

Codes Like Those for Myocardial Infarctions Now Involve Higher Level of Detail

In recent years, the Centers for Medicare & Medicaid Services (CMS) has increased the level of detail required for proper hospice coding—not only for reporting the direct reason a patient was put into hospice care, but also for any comorbidities not directly related to the patient’s terminal condition. Providing thorough details of such complex situations can easily trip up coders.

As part of a prerecorded event with AudioEducator, hospice coding expert Judy Adams reviews new hospice codes for 2018, as well as complex real-life situations where a patient may not have a clear diagnosis as the primary reason for being admitted into hospice care. Adams also reviews the new ICD-10-CM codes for 2018, including those related to heart conditions.

Distinguishing Between Types of Myocardial Infarctions

For 2018, a key subset of new and revised ICD-10-CM codes are those related to acute myocardial infarctions (AMI or MI). Although there are six types of AMIs, the two most frequently discussed are Type 1 and Type 2.

When it comes to submitting claims, it’s crucial to be able to distinguish which type of AMI occurred. Put simply, a Type 1 AMI is a spontaneous AMI related to ischemia (inadequate blood supply). This AMI would have occurred because of a primary coronary event such as thrombotic occlusion or plaque rupture. In contrast, a Type 2 AMI is secondary to ischemia and occurs because of a mismatch in the supply and demand of the myocardial oxygen supply.

2018 Changes to AMI Codes

The ICD-10-CM AMI codes this year focus heavily on Type 1 AMIs – namely, whether what occurred was an ST elevation myocardial infarction Type 1 (STEMI) or a Type 1 Non ST elevation myocardial infarction (NSTEMI).

A STEMI will typically be more of a “classic” heart attack with significant blockage in an artery, whereas an NSTEMI will present minor blockage in a major artery or full blockage in a minor artery.

For coding purposes, a STEMI would go under subcategories I21.0-I21.3, whereas NSTEMIs would be coded as I21.4. If the report does not state the site of disruption (anterior, inferior, lateral, or true posterior wall), then code I21.9 would be used. I21.9 is a new code now to be used with AMIs with unspecified site or type.

Sometimes you’ll find that a STEMI turns into an NSTEMI, or vice versa, which can be tricky for coding. It’s not as complicated as it seems, however: Just remember that STEMIs take precedence. If a Type 1 NSTEMI turns into a STEMI, you would code for a STEMI; if, however, a STEMI converts to an NSTEMI, you would still code for a STEMI.

Additional I21 Codes

Type 1 AMIs do receive the majority of attention this year in regards to coding, but we can’t forget about Type 2. For this type of AMI, you would code I21.A1, followed by the underlying cause – if such a code is known and applicable. These underlying causes include, but are not limited to:

  • Anemia
  • Renal failure
  • Shock
  • Chronic obstructive pulmonary disease (COPD)
  • Paroxysmal tachycardia


When coding for Type 2 AMIs, remember that you should only assign code I21.A1 – it’s not appropriate to use code I24.8 (other forms of ischemic heart disease).

If the AMI suffered was of type 3, 4a, 4b, 4c, or 5, use code I21.A9 according to the 2018 guidelines. Be sure to code any complications as well – such as stent occlusions, stent stenosis, stent thrombosis, or occlusion of coronary artery bypass graft.

Finalizing Successful Claims

As a coder, you’ve got a lot on your plate, and CMS’s requirements this year add even more. Hospice coding requirements are extensive—not just for MIs, but also for neoplasms, neurodevelopmental disorders, vision loss, and nervous system syndromes.

Continuous training is important to make sure you always have the right and most updated information. Proper codes help avoid rejected claims while keeping practices ticking along, which is why the detailed presentation by Adams is an ideal resource to help ensure you’re prepared for whatever coding changes and challenges come your way.

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