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.
ICD Codes |
Stroke type
|
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 |
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.
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.
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.