Learn about accurate clinical documentation and medical coding for a history of STEMI. This guide covers diagnosis codes (I25.2), ICD-10 coding, STEMI documentation requirements, and best practices for healthcare professionals dealing with patients with a prior ST-Elevation Myocardial Infarction. Understand the importance of complete medical records for optimal patient care and accurate reimbursement. Find information on past MI, previous STEMI, and history of heart attack coding guidelines.
Also known as
Old myocardial infarction
History of STEMI or unspecified MI.
Acute transmural MI of unspecified site
May be useful for recent STEMI if documented as transmural.
Chronic ischemic heart disease, unspecified
Less specific, use if other history of ischemic heart disease exists.
Follow this step-by-step guide to choose the correct ICD-10 code.
Documented history of STEMI?
Yes
Current episode of care related to STEMI?
No
Do not code history of STEMI. Code presenting condition.
When to use each related code
| Description |
|---|
| STEMI |
| NSTEMI |
| Unstable Angina |
Using I25.2 (Old MI) instead of a more specific code like I25.810 (STEMI history) leads to inaccurate risk adjustment.
Vague documentation like "heart attack" fails to distinguish STEMI from NSTEMI, impacting accurate coding and reimbursement.
Missing CDI query opportunities to clarify STEMI history when documentation is ambiguous can result in coding errors and lost revenue.
Patient presents with a history of ST-elevation myocardial infarction (STEMI). The date of the initial STEMI event is documented as [Date of Infarct]. The patient reports [Symptoms at time of initial STEMI e.g., chest pain, shortness of breath, diaphoresis]. Initial electrocardiogram (ECG or EKG) at the time of the infarct demonstrated [ECG findings e.g., ST-segment elevation in leads II, III, and aVF]. Cardiac biomarkers, specifically troponin, were elevated, confirming the diagnosis of myocardial infarction. The patient was treated with [Treatment strategy e.g., percutaneous coronary intervention (PCI), thrombolytic therapy, coronary artery bypass grafting (CABG)]. Current medications include [List current medications e.g., aspirin, clopidogrel, beta-blocker, ACE inhibitor, statin]. The patient currently reports [Current symptoms e.g., asymptomatic, angina, dyspnea]. Physical examination reveals [Current cardiac exam findings e.g., regular rate and rhythm, normal heart sounds, no murmurs, rubs, or gallops]. Assessment: History of STEMI. Plan: Continue current medical therapy. Patient education provided regarding medication adherence, lifestyle modifications including diet and exercise, and symptom recognition. Follow-up scheduled in [Duration] for repeat [Tests or evaluations e.g., ECG, echocardiogram, stress test]. Emphasis placed on cardiac rehabilitation and secondary prevention strategies to reduce risk of recurrent cardiovascular events.