Query IQ: “Stop Saying That!”

By Hassan Rao, MD and Robin Sewell

Have you seen the scene in The Princess Bride where Inigo Montoya spends his entire life hunting the six-fingered man who killed his father? When he finally confronts him, he repeats, “Hello. My name is Inigo Montoya…” 

Eventually, the six-fingered man snaps back: “Stop saying that!”

This echoes the sentiment CDI and coding professionals sometimes feel when providers repeatedly document phrases such as “elevated troponin” or “demand ischemia” instead of the terms “myocardial injury” or “myocardial infarction” (MI). This clinical and documentation specificity is needed for accurate  coding appropriate reimbursement and accurate tracking of quality measures. 

Why “Elevated Troponin” and “Demand Ischemia” Are Problematic  

The Fourth Universal Definition of Myocardial Infarction clearly differentiates these conditions, which are also amenable to ICD-10 code assignment: 

• Non-ischemic Myocardial injury 
• Type 2 myocardial infarction (T2MI) 
• Type 1 myocardial infarction (AMI) 

When providers document using vague or outdated terminology, they unintentionally create ambiguity – remember urosepsis? Phrases like “elevated troponin” or “demand ischemia” often lead to mischaracterization of the patient’s condition, a lack of specificity and/or unnecessary documentation queries.  

Elevated troponin is an observation and not a diagnosis. Providers may use this term initially until a definitive diagnosis of myocardial injury or infarction is identified. Elevated troponin should never be listed as a final diagnosis.  

Demand ischemia represents the pathophysiologic mechanism for an elevated troponin and should not be used as a standalone diagnosis. If an elevated troponin is due to demand ischemia, the provider should then consider if there are signs/symptoms of ischemia. If yes, the diagnosis should be Type 2 MI. If no, myocardial injury would be most appropriate. Using the term “demand ischemia” alone may result in confusion and a lack of specificity requiring a potential query.  

Recent Documentation Example 

Revisiting the Clinical Criteria… 

According to the Fourth Universal Definition of Myocardial Infarction, Type 2 MI requires: 

1. A rise and/or fall of cardiac troponin with at least one value above the 99th percentile AND 

2. Evidence of myocardial oxygen supply-demand imbalance unrelated to coronary thrombosis, plus at least one of the following: 
   • Symptoms of acute myocardial ischemia
   • New ischemic ECG changes
   • Development of pathological Q waves
   • Imaging evidence of new loss of viable myocardium or new regional wall-motion abnormality consistent with ischemia

By contrast, myocardial injury is defined simply as: 

“Detection of an elevated cardiac troponin value above the 99th percentile upper reference limit.” 

In the above case, the patient had echocardiographic evidence of anteroseptal hypokinesis—a regional wall-motion abnormality consistent with ischemia. Even in the absence of chest pain or ECG changes, this finding supports a diagnosis of Type 2 MI in the setting of elevated troponin levels. However, the query provided options that led to an inappropriate diagnosis of demand ischemia. 

The Ineffective Query

According to the H&P, the patient was noted to have elevated troponin levels up to 1000 in the setting of sepsis. Additional documentation includes: “possible demand ischemia” in a progress note, “myocardial injury” in the discharge summary, and echocardiogram findings of “anteroseptal hypokinesis.” 

Can this clinical evidence and documentation be further clarified as:  

By adding options for “demand ischemia” and “myocardial injury,” the CDI or Coding Professional may  have unintentionally led the provider away from the most clinically accurate diagnosis. 

Query Tip 

Remember, the Query Practice Brief instructs us to add only clinically relevant options and to exclude all clinically irrelevant options. 

Coding Tip 

Type 2 MIs and Myocardial Injury should generally not be coded as principal diagnosis due to the instructional note indicating to “Code first, if applicable, the underlying cause” 

Here’s a practical reference to assist in query construction. 

Criteria	Myocardial Injury (Non-Ischemic)	Type 2 MI	Type 1 MI
Elevate troponin	Yes	Yes	Yes
Ischemic symptoms	No	Yes*	Yes*
ECG or Echo changes	No	Yes*	Yes*
Acute cath findings	No	No	Yes
ICD-10-CM code	I5A (CC)	I21.A1 (MCC)	I21.4** (MCC)
Code first underlying cause	Yes	Yes	No

*For acute MI, ischemia may be demonstrated by symptoms or  objective findings (ECG or imaging). **Actual code assignment may vary depending on site of infarction. 

The Takeaway

When you see “elevated troponin” or “demand ischemia,” pause. Review the record. Look for imaging, ECG changes, hemodynamic stressors, and clinical context. 

Educate your providers on key points:   

• “Elevated troponin” should never be a final diagnosis.  
• The term “demand ischemia” should not be a standalone diagnosis. Demand ischemia should be further specified as a definitive diagnosis of myocardial injury or type 2 myocardial infarction .  
• Use the 4^th Universal Definition of MI when applying the diagnosis of myocardial injury or type 2 MI  

Through education and effective queries, eventually, they will, “Stop documenting that!”