Menu
Question:
Cardiology documented the following in a patient progress note on the second hospital day: “Troponins +, highest 6.4, needs cath STAT. + chest pain.” The chart has no further clarification, so what would be the principal diagnosis on discharge?
Answer:
The prinicipal diagnosis would be “chest pain.” And you would need to send a query such as the following to the physician: “Acute myocardial infarction as cause of chest pain. Read cath lab note to further specify TYPE of MI if possible.”
This question was answered in the 2018 edition of 2018 Essentials for Clinical Documentation Integrity. For more hot topics relating to cardiology services, please view our store, or call us at 1.800.252.1578 ext. 2.
CPT® copyright 2021 American Medical Association (AMA). All rights reserved.
Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.
CPT is a registered trademark of the American Medical Association.
Subscribe to receive our News, Insights, and Compliance Question of the Week delivered right to your inbox.
Address: 445 Minnesota Street, Suite 514
St. Paul, MN 55101
Phone: (800) 252-1578
Email: support@medlearnmedia.com
Hours: 9am – 5pm CT
Copyright © 2022 MedLearn Publishing. Powered by MedLearn Media.
