Diagnosis Code Tip Sheet: Stroke/CVA and Sequela
Diagnosis Code Tip Sheet: Stroke/CVA and Sequela
Documentation Considerations
Document vessel affected:
o Precerebral
o Cerebral
o Cerebellar Document residual findings of the stoke with treatment plant and follow-
up care Identify acuity of event (acute, healed, residual effects or sequelae)
Stroke without Residual Deficits
Z86.73
Personal history of CVA with no residual deficits
Sequela of Cerebral Infarction
I69.30
Unspecified sequelae of CI
I69.310 I69.311
Attention and concentration deficit following CI Memory deficit following CI
I69.312 I69.313
Visuospatial deficit and spatial neglect following CI Psychomotor deficit following CI
I69.314 I69.315 I69.318
Frontal lobe and executive function deficit following CI Cognitive social or emotional deficit following CI Other symptoms and signs involving cognitive functions following CI
I69.319
Unspecified symptoms and signs involving cognitive functions following CI
I69.320
Aphasia following CI
I69.321
Dysphasia following CI
I69.322
Dysarthria following CI
I69.323
Fluency disorder following CI
I69.328 I69.331
Other speech and language deficits following CI Monoplegia of upper limb following CI affecting right dominant side
Diagnosis Considerations
Active stroke is only coded while in a hospital setting Code for residual effects when being seen for follow-up (hemiplegia,
hemiparesis, aphasia, etc.)
Code for "history of stroke" if patient has no
residual effects from the stroke
I69.332 Monoplegia of upper limb following CI affecting left dominant side
I69.333 Monoplegia of upper limb following CI affecting non-dominant side
I69.334 Monoplegia of upper limb following CI affecting left non-dominant side
I69.339 Monoplegia of upper limb following CI affecting unspecified side
I69.341 Monoplegia of lower limb following CI affecting right dominant side
I69.342 Monoplegia of lower limb following CI affecting left dominant side
I69.343
Monoplegia of lower limb following CI affecting right non-dominant side
I69.344 Monoplegia of lower limb following CI affecting left non-dominant side
I69.349 Monoplegia of lower limb following CI affecting unspecified side
I69.351 Hemiplegia & hemiparesis following CI affecting right dominant side
I69.352 Hemiplegia & hemiparesis following CI affecting left dominant side
I69.353
Hemiplegia & hemiparesis following CI affecting right non-dominant side
I69.354
Hemiplegia & hemiparesis following CI affecting left non-dominant side
I69.359 Hemiplegia & hemiparesis following CI affecting unspecified side
I69.361 Other paralytic syndrome following CI affecting right dominant side
Highmark Blue Cross Blue Shield of Western New York and BlueCross BlueShield of Western New York are trade names of Highmark Western and Northeastern New York Inc., an independent licensee of the Blue Cross Blue Shield Association.
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Additional Considerations
Document patient's dominant side Document laterality of affected side (right or left) Provide clarification and details when symptoms are new and unrelated to history of stroke sequela
I69.362
Other paralytic syndrome following CI affecting left dominant side
I69.363
Other paralytic syndrome following CI affecting right non-dominant side
I69.364
Other paralytic syndrome following CI affecting left non-dominant side
I69.365
Other paralytic syndrome following CI, bilateral
I69.369
Other paralytic syndrome following CI affecting unspecified side
I69.390
Apraxia following CI
I69.391
Dysphagia following CI
I69.392
Facial weakness following CI
I69.393
Ataxia following CI
I69.398
Other sequelae of cerebral infarction
NOTE: Shown are the codes for sequelae of cerebral infarction. Please reference ICD-10-CM coding resources for the categories below if other sequelae codes are required:
I69.0X = Sequelae of nontraumatic subarachnoid hemorrhage I69.1X = Sequelae of nontraumatic intracerebral hemorrhage I69.2X = Sequelae of other nontraumatic intracranial hemorrhage I69.8X = Sequelae of other cerebrovascular diseases I69.9X = Sequelae of unspecified cerebrovascular diseases
NOTE: This tool is intended to assist with documentation only and not intended to take the place of clinical analysis. Information regarding any law or regulation does not constitute legal or tax advice and is subject to change based upon the issuance of new guidance and/or change in laws or regulations. Reference Official ICD-10-CM coding guidelines and manuals or electronic medical coding software for accurate ICD-10-CM codes and specificity.
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