Documentation and Coding: CVA with Sequelae
Documentation and Coding:
CVA with Sequelae
Created March 2021
At Healthfirst, we are committed to helping providers accurately document and code their patients' health records. This tip sheet is intended to assist providers and coding staff with the documentation and ICD-10-CM selection on services submitted to Healthfirst. It provides information from industry sources about proper coding practice. However, this document does not represent or guarantee that Healthfirst will cover and/or pay for services outlined. Coverage decisions are based on the terms of the applicable evidence of coverage and the provider's participation agreement. This includes the determination of any amounts that Healthfirst or the member owes the provider.
Codes in this category describe the type of stroke and the sequelae (late effects) caused by the stroke. Documentation should clearly state whether a neurological deficit is directly related to cerebrovascular disease or a cerebrovascular accident. Ensure that all diagnoses reported are supported by the MEAT (Monitoring, Evaluating, Assessing, Treating) concept.
Coding Examples of CVA with Sequelae
Example 1: Patient presents with a history of cerebral infarction. She has residual dysphasia and
is being treated by a neurologist.
ICD - 10 - CM I69.321
Code Category
Dysphasia following cerebral infarction
Supported Diagnosis
History of stroke with residual effects (dysphasia) has been clearly documented.
To accurately code sequelae (late effects) of cerebrovascular disease, the side of the body affected should be clearly documented in the medical record. If the affected side is documented, but not specified as dominant or non-dominant, and the classification system does not have a default, the code selection is as follows:
If the right side is affected, the default is dominant.
If the left side is affected, the default is non-dominant.
For ambidextrous patients, the default should be dominant.
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Documentation and Coding:
CVA with Sequelae
Coding Examples of CVA with Sequelae (continued)
Example 2: Patient presents with a history of non-traumatic intracerebral hemorrhage
with residual hemiplegia affecting the right side.
ICD - 10 - CM
Code Category
I69.151
Hemiplegia and hemiparesis following non-traumatic intracerebral hemorrhage
affecting right dominant side
Supported Diagnosis
History of non-traumatic intracerebral hemorrhage with residual hemiplegia affecting the right side. For documentation that does not clearly specify whether the right side is dominant or non-dominant, dominant
should be the default.
Example 3: Patient presents with a history of cerebral infarction with residual monoplegia
of the lower limb affecting the left side.
ICD - 10 - CM
Code Category
Supported Diagnosis
I69.344
Monoplegia of lower limb following cerebral
infarction affecting left non-dominant side
For documentation that does not clearly specify whether the left side is dominant
or non-dominant, non-dominant should be the default.
Example 4: Ambidextrous patient presents with a history of non-traumatic subarachnoid hemorrhage
with residual hemiplegia affecting the left side.
ICD - 10 - CM
Code Category
Supported Diagnosis
I69.052
Hemiplegia and hemiparesis following non-traumatic subarachnoid hemorrhage
affecting left dominant side
Documentation clearly specifies history of non-traumatic subarachnoid hemorrhage with
residual hemiplegia affecting the left side.
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Documentation and Coding:
CVA with Sequelae
Coding Examples of CVA with Sequelae (continued)
When coding sequelae (late effects) of cerebrovascular disease, the documentation should ALWAYS clearly state the sequela or residual effect. If the documentation does not specify what the sequela is, an unspecified code can be selected.
Example 1: Patient presents with history of non-traumatic intracranial hemorrhage with
residual effects.
ICD - 10 - CM I69.20
Code Category
Unspecified sequelae of other non-traumatic
intracranial hemorrhage
Supported Diagnosis
Documentation does not clearly specify residual effects.
Example 2: Patient suffers a non-traumatic subarachnoid hemorrhage of both anterior
communicating arteries.
ICD - 10 - CM I60.2
Code Category
Non-traumatic subarachnoid hemorrhage from anterior communicating artery
Supported Diagnosis
Documentation clearly states history of hemorrhage of both anterior communicating arteries.
Example 3: Patient has a bilateral stenosis of the vertebral arteries.
ICD - 10 - CM
Code Category
Supported Diagnosis
I65.03
Occlusion and stenosis of bilateral vertebral arteries
Documentation clearly states bilateral stenosis of the vertebral arteries.
Ensure that all diagnoses reported are supported by the MEAT (Monitoring, Evaluating, Assessing, Treating) concept.
Questions?
Contact us at #Risk_Adjustments_and_clinical_Documentation@. For additional documentation and coding guidance, please visit the Coding section at .
Reference: .
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