General Discussions

Coding strokes

 
Picture of Robin McE
Coding strokes
by Robin McE - Sunday, 2 April 2017, 9:59 AM
 

Hi everyone!  I probably missed this somewhere along the way, but when you read the entry and it states the pt. had a right hemispheric stroke with severe left-sided deficits.  It does not say whether pt was right or left-sided dominant .Do you put unspecified side because you don't kn11ow what their dominant side is??  Working on the CCW 10 exercises, and  WOW!  THANKS FOR YOUR HELP!


Robin

Picture of Wendy Va, CCS, COC, CPC, CRC
Re: Coding strokes
by Wendy Va, CCS, COC, CPC, CRC - Sunday, 2 April 2017, 11:59 AM
 

Hi Robin, here are the coding guidelines below:

Cerebrovascular Accident and Disease

9. Chapter 9: Diseases of Circulatory System (I00-I99)

d. Sequelae of Cerebrovascular Disease

1) Category I69, Sequelae of Cerebrovascular disease

Category I69 is used to indicate conditions classifiable to categories I60-I67 as the causes of sequela (neurologic deficits), themselves classified elsewhere. These "late effects" include neurologic deficits that persist after initial onset of conditions classifiable to categories I60-I67. The neurologic deficits caused by cerebrovascular disease may be present from the onset or may arise at any time after the onset of the condition classifiable to categories I60-I67.

Codes from category I69, Sequelae of cerebrovascular disease, that specify hemiplegia, hemiparesis and monoplegia identify whether the dominant or nondominant side is affected. Should the affected side be documented, but not specified as dominant or nondominant, and the classification system does not indicate a default, code selection is as follows:

  • For ambidextrous patients, the default should be dominant.
  • If the left side is affected, the default is non-dominant.
  • If the right side is affected, the default is dominant.

2) Codes from category I69 with codes from I60-I67

Codes from category I69 may be assigned on a health care record with codes from I60-I67, if the patient has a current cerebrovascular disease and deficits from an old cerebrovascular disease.

3) Codes from category I69 and Personal history of transient ischemic attack (TIA) and cerebral infarction (Z86.73)

Codes from category I69 should not be assigned if the patient does not have neurologic deficits.

See Section I.C.21. 4. History (of) for use of personal history codes

Hope this helps!
Picture of Instructor Peggy
Re: Coding strokes
by Instructor Peggy - Sunday, 2 April 2017, 1:01 PM
 

Robin, the answer to your question is in the Official Coding Guidelines.  Those should be in your ICD-10-CM manual. Please let us know if you can't find them.