Find information on documenting and coding a history of myocardial infarction (MI) for accurate clinical records. This resource covers heart attack history, previous MI, acute MI, old MI, prior MI, and related terms like documented MI, history of cardiac arrest, coronary artery disease history, and ischemic heart disease history. Learn about ICD-10 codes for history of MI, diagnosis of previous MI, and proper medical coding for prior heart attack. Explore best practices for healthcare documentation and improve your clinical coding accuracy for patients with a history of heart attack.
Also known as
Old myocardial infarction
Previous heart attack diagnosed by EKG or imaging.
Acute myocardial infarction
Recent heart attack, not appropriate for history.
Personal history of MI
Use for history of MI when other codes are inappropriate.
Follow this step-by-step guide to choose the correct ICD-10 code.
Documented history of MI?
Yes
Type of MI documented?
No
Do NOT code for history of MI. Review documentation for alternative diagnoses.
When to use each related code
| Description |
|---|
| History of heart attack |
| Silent myocardial infarction |
| Old myocardial infarction |
Coding I21.9 (AMI, unspecified) when documentation supports a more specific AMI type (STEMI/NSTEMI) leads to inaccurate risk adjustment and reimbursement.
Miscoding angina as an AMI or vice versa due to similar symptoms impacts data integrity for quality reporting and clinical outcomes analysis.
Lack of sufficient documentation like EKGs, cardiac enzyme levels, or physician notes to validate AMI diagnosis causes audit denials and compliance issues.
Patient presents with a history of myocardial infarction (MI), commonly referred to as a heart attack. The date of the MI is documented as [Date of MI]. The patient reports [Symptoms experienced during MI event e.g., chest pain, shortness of breath, diaphoresis, nausea, radiating pain to left arm]. Initial cardiac enzyme levels at the time of the event were [Cardiac enzyme levels e.g., Troponin I, CK-MB]. Electrocardiogram (ECG) findings at the time of the MI indicated [ECG findings e.g., ST-segment elevation, Q waves]. The patient's MI was classified as [Type of MI e.g., STEMI, NSTEMI]. Subsequent cardiac catheterization revealed [Findings from cardiac catheterization e.g., coronary artery stenosis, occlusion]. Treatment included [Medications and interventions e.g., percutaneous coronary intervention (PCI), thrombolytic therapy, aspirin, beta-blockers, ACE inhibitors, statins]. Current medications for secondary prevention of MI include [List current medications]. The patient is currently experiencing [Current symptoms related to history of MI, if any]. Physical examination reveals [Relevant cardiovascular findings e.g., heart rate, rhythm, murmurs, lung sounds, edema]. Assessment: History of myocardial infarction with [Specify any complications e.g., heart failure, arrhythmias]. Plan: Continue current medications. Patient education provided on lifestyle modifications including diet, exercise, and smoking cessation. Follow-up scheduled in [Duration] to monitor cardiac status and medication effectiveness. ICD-10 code: I25.2 (Old myocardial infarction).