Learn about Non-ST Elevation Myocardial Infarction (NSTEMI) diagnosis, clinical documentation requirements, and medical coding guidelines. Find information on NSTEMI symptoms, ECG changes, troponin levels, and risk factors. This resource covers appropriate ICD-10 codes, documentation best practices for healthcare professionals, and clinical criteria for NSTEMI diagnosis. Explore the differences between NSTEMI and STEMI, understand the importance of accurate clinical documentation, and ensure proper medical coding for optimal reimbursement.
Also known as
Non-ST elevation MI
Heart attack without ST elevation on EKG.
Angina pectoris
Chest pain due to reduced blood flow to the heart.
Myocardial infarction type
Classifies the specific type of heart attack.
Atherosclerotic heart disease
Narrowing of heart arteries due to plaque buildup.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the diagnosis NSTEMI?
Yes
Type 1 or Type 2 NSTEMI?
No
Do NOT code as NSTEMI. Evaluate for other diagnosis.
When to use each related code
| Description |
|---|
| Non-ST Elevation MI (NSTEMI) |
| Unstable Angina |
| ST Elevation MI (STEMI) |
Insufficient documentation of elevated troponin levels with ischemic symptoms to support NSTEMI diagnosis.
Misdiagnosis of NSTEMI as STEMI or unstable angina due to ECG interpretation or symptom ambiguity.
Incorrectly coding Type 2 MI as NSTEMI without documenting secondary cause of myocardial ischemia.
Patient presents with symptoms suggestive of non-ST elevation myocardial infarction (NSTEMI). The patient reports acute onset of chest pain, described as pressure or tightness, radiating to the left arm and jaw. Associated symptoms include diaphoresis, nausea, and shortness of breath. Risk factors for coronary artery disease include hypertension, hyperlipidemia, and a family history of heart disease. Electrocardiogram (ECG) shows T-wave inversions in the anterior leads, without ST-segment elevation. Cardiac biomarkers, including troponin I and troponin T, are elevated, confirming the diagnosis of NSTEMI. The patient was administered aspirin, nitroglycerin, and a beta-blocker. Anticoagulation therapy with heparin was initiated. The patient is being evaluated for coronary angiography and possible percutaneous coronary intervention (PCI). Differential diagnosis includes unstable angina, pericarditis, and musculoskeletal chest pain. Assessment and plan include continuous cardiac monitoring, serial cardiac enzymes, and assessment of hemodynamic stability. The patient's current condition is stable, and they are being admitted for further management of NSTEMI. Medical coding will reflect the diagnosis of NSTEMI and associated procedures, including ECG, cardiac enzyme testing, and administration of medications. This documentation supports medical billing for hospital admission and treatment of NSTEMI.