By: Caliay Pratt, CPC, CDEO, CRC, CRHC
We have all seen it before, you open the chart, and it says the patient had a stroke. So, you open your ICD-10-CM book and search for cerebral vascular accident, but there are so many variables and seemingly endless options. Where do you go from here?
Before we jump into the coding aspect, let us take a step back and consider the pathophysiology of a cerebrovascular accident (CVA), otherwise known as a stroke or a cerebral infarction. A cerebrovascular accident is when there is a loss of blood flow to part of the brain. The brain cells cannot get oxygen and nutrients they need from blood and the brain cells start to die within a few minutes, leading to potential brain damage, long-term disability, and even death in some cases.
There are two types of strokes, ischemic and hemorrhagic. An ischemic stroke, also known as a cerebral infarction, is caused by a disrupted blood flow to the brain due to problems with blood supply, such as a blood clot (thrombosis) or a piece of plaque. This is the most common type of stroke. A hemorrhagic stroke is when a blood vessel in your brain ruptures and bleeds. The bleeding can disrupt the natural circulation of blood and starve some areas of oxygen and the accumulation of blood in other areas of the surrounding brain can damage or destroy it.
In an outpatient setting it’s very unlikely that a patient would be having a definitive stroke that a provider could accurately document and code as a stroke. These conditions would more likely be diagnosed in the hospital setting after thorough examination and testing. If you see a stroke code in the problem list or the assessment/plan it is a pretty good indicator that the wrong code was selected.
So, what codes would be appropriate in the outpatient setting then? In the primary care outpatient setting we are mostly going to see patients that have residual deficits (sequelae or late effects) and patients that have a history of a cerebrovascular accident. For this article, I will stick to those coding guidelines and tips.
After a patient has been discharged from the initial episode of treatment for an acute CVA any remaining residual deficits are considered a sequela. After discharge, if there are no residual side effects, you would code Z86.73 (Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits).
Codes from category I69 should be assigned for residual side effects of a CVA. The fourth character of the ICD-10 code specifies the casual conditions of the residual deficit, the fifth character specifies the deficit, and the sixth character specifies the laterality, if applicable. Considerations for residual side effects include attention and concentration deficit, memory deficit, aphasia, dysphasia, monoplegia, hemiplegia, hemiparesis, among others. Verify first that there is documentation clearly linking the residual deficit to the past CVA as the cause. Look for documentation that the deficit is still present and current as well. For example, if the final diagnosis is hemiparesis due to past CVA, the physical exam should mention the hemiparesis somewhere.
The codes under I69 specify hemiplegia, hemiparesis, and monoplegia as either dominant or non-dominant. If that is not specified in the documentation, code selections are as follows:
- Ambidextrous patients: the default is dominant
- If the left side is affected: the default is non-dominant
- If the right side is affected: the default is dominant
Code set is I69.33-I69.35 (requires a 6th digit to specify laterality)
When a residual deficit is documented as “history of” it should not be coded as current if there is no documentation to support that the deficit is still present.
If unilateral weakness due to a past CVA is documented that is considered synonymous with hemiparesis and should be coded as such. Use code I69.35 (requires a 6th digit to specify laterality).
If it is documented that the patient has residual weakness due to a past CVA and nothing else in the documentation specifies site, it should be coded with I69.398 (Other sequelae of cerebral infarction) and R53.1 (Weakness). If the document specifies that it is muscle weakness then you would code M62.81 (Muscle weakness (generalized)) rather than R53.1.
There are some additional documentation considerations to make so that the coders can select the most appropriate codes:
- The type of CVA – ischemic, hemorrhagic, postoperative, etc.
- The affected artery – intracerebral, intracranial, subarachnoid
- The cause, if known
- For residual side effects document the laterality (dominant or non-dominant) or the type (dysphagia oral phase, pharyngeal phase etc.)
- Make sure to link the residual side effect to the past CVA
- The time frame – was the patient just discharged from their initial care last week? Is this care for a late effect? Or is this something that happened three years ago? Is this historical? Etc.
- Do not document a CVA as “history of” unless it truly is a condition that no longer exists
- A clear treatment plan for the residual deficits – “Will send the patient to “x” provider for physical therapy of hemiparesis due to past CVA and will follow up in 3 months.”
Thorough documentation and review of the record is imperative to obtain the level of specificity and detail that is available with ICD-10. In review, it is very unlikely that a patient having an active cerebrovascular accident will be seen in an outpatient clinic. So, you can narrow down code selection to two choices, residual side effects of a CVA or history of a CVA. If there are no residual side effects, then always select the history of CVA. I hope that you are now armed with the tools to confidently be able to pick the most appropriate cerebrovascular accident!
Source: ICD-10-CM: The Complete Official Codebook. (2023). American Medical Association.
