I34.0 - Nonrheumatic mitral (valve) insufficiency

Clinical Definition

A Myocardial Infarction (MI), commonly known as a heart attack, occurs when blood flow to a part of the heart muscle is blocked, causing tissue damage or death. The "initial episode of care" refers to the first medical encounter and immediate follow-up care for the acute event.

Documentation Requirements

• Specific timing must be noted:

  • Document exact date and time of onset

  • Clearly state "initial" encounter

  • Duration since symptom onset (<24 hours, >24 hours)

• Anatomical location:

  • Specify wall affected (anterior, inferior, lateral, etc.)

  • Note if ST elevation (STEMI) or non-ST elevation (NSTEMI)

• Severity indicators:

  • Troponin levels

  • EKG findings

  • Percentage of heart muscle affected

• Associated conditions:

  • Presence/absence of complications

  • Pre-existing cardiac conditions

Common Synonyms

• Heart attack

• Coronary attack

• Cardiac arrest (incorrect but commonly used by patients)

• Coronary thrombosis

• "The Big One"

Coding Conflicts

Excludes1:

• Old or healed myocardial infarctions

• Post-myocardial infarction syndrome

• Subsequent episodes of care

Excludes2:

• Demand ischemia (I24.8)

• Postinfarction angina (I23.7)

Scribing.io Automation

The AI scribe automatically:

• Identifies temporal markers indicating initial presentation

• Flags key cardiac enzyme values

• Maps anatomical references to standard MI locations

• Captures EKG interpretation details

• Tags complications for appropriate coding

• Highlights timing elements crucial for initial vs. subsequent care determination

Remember to document the exact time-to-treatment intervals for quality metrics and proper coding assignment.