Coding and Documentation Guidelines for Stroke and Infarction

In ICD-10 CM, code category I63 should be utilized when the medical documentation indicates that an infarction or stroke has occurred. Coding of sequelae of stroke and infarction also demands a level of detail often missing in medical records. There are specific codes which indicate the cause of the infarction, such as embolism or thrombosis, as well as the specific affected arteries. The sixth digit provides additional information which designates the affected side when applicable. 

 

Seek answers to two questions when coding a stroke, infarction, or hemorrhage. First, ask if the cerebral event is acute, or emergent. Second, find in the medical record details of the site and the site, laterality, and type of stroke or infarction. Medical record documentation should clearly specify the cause-and-effect relationship between the medical intervention and the cerebrovascular accident in order to assign a code for an intraoperative or postprocedural cerebrovascular accident.

Clinical Scenario

The patient is admitted into hospital and diagnosed with cerebral infarction, unspecified (ICD-10 code I63.9). At the 3-week post-discharge follow-up appointment for the cerebral infarction, the office visit note states the patient had a stroke and has a residual deficit of hemiplegia, affecting the right dominant side.

In the scenario described above, assigning ICD-10 code I69.351, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, accurately reflects the documentation in the medical record. Any insurance company reviews provider documentation to ensure the accuracy of diagnosis codes reported.

• Once the patient is discharged, it is not appropriate to code for the cerebral infarction. Instead, you would code any and all residual deficits the patient has.
• If the patient does not have any cerebral infarction deficits, you can apply the ICD-10 code Z86.73, personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits, if supported by the documentation in the chart.

Coding Guidelines

• Documentation of unilateral weakness in conjunction with a stroke is considered by the ICD to be hemiparesis/hemiplegia due to the stroke and should be reported separately. Hemiparesis is not considered a normal sign or symptom of stroke and is always reported separately.
• If the patient’s dominant side is not documented, assume the left side is non-dominant, except for ambidextrous patients. In ambidextrous patients, assume the affected side is dominant.
• Report any and all neurological deficits of a cerebrovascular accident that are exhibited anytime during a hospitalization, even if the deficits resolve before the patient is released from the hospital.
• Once the patient has completed the initial treatment for stroke and is released from acute care, report deficits with codes from I69 Sequelae of cerebral infarction. Neurologic deficits may be present at the time of the acute event or may arise at any time after the condition reported with I60-I67.
• If the provider is not specific in recording the site of a stroke or infarction, it is permissible for coders to use the accompanying CT scans or other radiological reports to report the specific anatomic site.
• Codes I60-I69 should never be used to report traumatic intracranial events.
• Normally, do not report codes from I80-I67 with codes from I69. However, if the patient has deficits from an old cerebrovascular event and is currently having a new cerebrovascular event, both may be reported.
• If a patient has a history of a past cerebrovascular event and has no residual sequelae, report Z86.73 Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits.
• If a patient is diagnosed with bilateral nontraumatic intracerebral hemorrhages, report I61.6 Nontraumatic intracerebral hemorrhage, multiple localized. For bilateral subarachnoid hemorrhage, assign a code for each site. Categories I65 and I66 have unique codes for bilateral conditions.
• Also code any documented atrial fibrillation, CAD, diabetes, or hypertension as these comorbidities are stroke risk factors.

The amount of specificity and detail available in ICD-10 CM makes complete and accurate documentation essential. Coders will need to thoroughly review the record in order to locate and assign the correct diagnosis code. Insurance companies review provider documentation to ensure the accuracy of diagnosis codes reported. Connecting with professional medical billing company like Medical Billers and Coders (MBC) could help in streamlining your billing activities. Contact us at 888- 357-3226/ info@medicalbillersandcoders.com for more information.

FAQs

1. What ICD-10 codes are used for coding strokes and infarctions?

• The ICD-10 codes for strokes and infarctions include:

  • I60.- Spontaneous subarachnoid hemorrhage
  • I61.- Spontaneous intracerebral hemorrhage
  • I62.- Spontaneous subdural hemorrhage
  • I63.0-I63.2 Thrombosis/embolus precerebral arteries
  • I63.3-I63.5 Thrombosis/embolus cerebral arteries
  • I63.6 Venous thrombosis
  • I63.8 Other specified cerebral infarction
  • I63.9 Unspecified cerebral infarction
  • G45.9 Transient cerebral ischemic attack, unspecified (TIA)
  • Z86.73 Personal history of TIA or cerebral infarct without residual deficits

2. How do you determine the correct ICD-10 code for a stroke or infarction?

• To determine the correct ICD-10 code, identify the type of stroke or infarction, specify the affected arteries, and document any residual deficits. Accurate coding requires detailed documentation of the event’s acute nature, site, laterality, and specific causes.

3. What is the significance of the sixth digit in ICD-10 codes for strokes and infarctions?

• The sixth digit provides additional details about the affected side when applicable. For instance, codes for hemiplegia may indicate whether the deficit affects the right or left side of the body.

4. When should I use the I69.351 code for stroke-related documentation?

• The I69.351 code is used when documenting hemiplegia or hemiparesis following a cerebral infarction affecting the right dominant side, accurately reflecting the documentation in the medical record.

5. What should be coded after a patient is discharged following a stroke or infarction?

• After discharge, code any residual deficits such as hemiplegia or other neurological issues. If no residual deficits are present, use Z86.73 for a personal history of TIA or cerebral infarction without residual deficits.

6. Can you code for stroke deficits if they resolve before discharge?

• Yes, report any neurological deficits exhibited during hospitalization, even if they resolve before discharge. Use codes from the I69 category for sequelae of cerebral infarction.

7. What should be done if the provider’s documentation lacks specific details about the stroke or infarction?

• Use CT scans or other radiological reports to determine the specific anatomic site if the documentation is vague. Ensure that all available documentation is reviewed for accurate code assignment.

8. How should bilateral nontraumatic intracerebral hemorrhages be coded?

• For bilateral nontraumatic intracerebral hemorrhages, use I61.6 for multiple localized hemorrhages. For bilateral subarachnoid hemorrhages, assign a code for each site, with categories I65 and I66 having unique codes for bilateral conditions.

9. Should comorbidities such as atrial fibrillation or diabetes be coded when documenting strokes?

• Yes, comorbidities like atrial fibrillation, coronary artery disease (CAD), diabetes, and hypertension should be coded as they are risk factors for stroke.

10. What are the documentation standards for coding?

• Documentation standards for coding require that the medical record clearly describes the patient's condition, including specific details about the diagnosis, site, laterality, and any residual effects. The documentation should be detailed enough to support the codes assigned and reflect the severity and complexity of the condition.

11. What are coding rules and guidelines?

• Coding rules and guidelines include:
  • Accuracy: Codes must accurately reflect the diagnosis as documented.
  • Specificity: Use the most specific code available to describe the condition.
  • Sequencing: Follow coding guidelines for sequencing primary and secondary diagnoses.
  • Use of Modifiers: Apply appropriate modifiers to provide additional information about the service or item.
  • Updates: Stay current with changes to coding systems and guidelines, including updates to ICD-10 and CPT codes.

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Published By - Medical Billers and Coders
Published Date - Apr-19-2021 Back