During an ischemic stroke, not enough blood reaches the brain because arteries are blocked or narrowed. In ischemic or nonhemorrhagic strokes, the artery affected should be identified. The patient also has a known history of bilateral carotid stenosis. The coder should never assume that an infarction has occurred without this being clearly identified in the medical record. When codes from the 430-437 series are used, additional codes are needed to identify any sequelae or neurological deficits such as hemiplegia or aphasia.
The correct code assignment for the principal diagnosis is 435. Hemorrhagic strokes are frequently caused by aneurysms. Atrial fibrillation is a common cause of embolic strokes. By the time of discharge, the deficits have subsided with the possible exception of some weakness. These late effects include neurological deficits that persist after the initial onset of the cerebrovascular event. Coding Cerebrovascular DiseaseCodes from categories 430-434 should be used when coding the initial episode of care for an acute cerebral hemorrhage, occlusion, thrombosis, infarction or stroke. Each component of the diagnosis documented by the physician identifying cerebrovascular disease should be coded unless the alphabetic index or the tabular list instructs otherwise.
Always query the physician when the documentation is incomplete or unclear. Nonhemorrhagic Stroke Thrombosis: A blood clot thrombus forms inside an artery in the brain, blocking blood flow. A fifth digit of 1 is reported when there is documentation of a cerebral infarction. More information about 3M Health Information Systems is available at www. The company and its representatives do not assume any responsibility for reimbursement decisions or claims denials made by providers or payers as the result of the misuse of this coding information.
November 9, 2009 Coding for Cerebral Infarction For The Record Vol. Personal history codes explain a patient's past medical condition that no longer exists and is not receiving any treatment. The deficit may last from 5 minutes to 24 hours and is referred to as reversible. Records also lack specificity in the documentation and the change will allow improved uniformity and statistical data, and prevent unnecessary queries to the physician. Code assignment may change based on stroke type. . Hemorrhagic Stroke Subarachnoid hemorrhage: The bleeding occurs in the space between the brain and the skull.
A history of an illness, even if no longer present, is important information that may affect the type of treatment ordered. A stroke occurs when blood vessels carrying oxygen to a part of the brain suddenly burst or become blocked. Once a patient has completed the initial treatment or is discharged from care, codes from category 438, Late effects of cerebrovascular disease should be assigned to identify the residual neurologic deficits or late effects of cerebrovascular disease. The clot reaches a point where it can go no further and plugs the vessel, cutting off the blood supply. Codes from Categories 433, Occlusion and stenosis of precerebral arteries and 434, Occlusion of cerebral arteries use a fifth digit to indicate the presence or absence of an infarct during the current episode of care.
Common ischemic strokes include thrombotic stroke 434. An infarct is an area of necrosis, or tissue death, due to obstruction of a blood vessel by a thrombus, embolus or a hemorrhagic or ischemic event. Code 436, Acute but ill-defined cerebrovascular disease, is used when the medical record documents apoplectic attack, cerebral apoplexy, apoplectic seizure or cerebral seizure. Intracerebral hemorrhage: A defective artery within the brain bursts, flooding the surrounding brain tissue with blood. For example: cerebrovascular arteriosclerosis with subarachnoid hemorrhage due to ruptured aneurysm is coded to 430 and 437. In hemorrhagic strokes, the site of the hemorrhage should be documented.
Embolism: A clot, originating somewhere other than the brain, breaks loose and is carried by the blood stream to the brain. The signs and symptoms are the same as a stroke but last for a shorter period of time, usually minutes to 24 hours, with no residual effects. Strokes fall into several major categories, based on whether the disrupted blood supply is caused by a blocked blood vessel ischemic stroke or a hemorrhage. When appropriate, a code from category V12. Codes from category 437 are used to identify other and ill-defined cerebrovascular diseases such as cerebral arteriosclerosis, nonruptured cerebral aneurysms and arteritis and transient global amnesia. Strokes can also be treated surgically with carotid endarterectomy 38. Use an appropriate code from the category 435, Transient cerebral ischemia, when neurological deficits are of sudden onset and brief duration due to insufficiency of cerebral circulation.
It is also one of the top 10 conditions leading to hospital admission in the United States, involving more than 1 million hospitalizations in 1998. The Medicare Grouper assigns code 434. For example: A patient is admitted because of repeated, brief episodes of light-headedness and left-sided tingling over the past week. The physician must document that the stroke occurred as a result of the occlusion or stenosis before the fifth digit of 1 can be assigned. A hemorrhagic stroke occurs when a blood vessel in the brain leaks or ruptures.
However, if the aphasia is still present at discharge both codes 434. Some of the symptoms eventually subside, while others are never completely resolved. Ischemic strokes account for 80 percent of all strokes. For example: A 62-year-old male is diagnosed with an acute cerebral infarction due to thrombosis. The clot may occur in the cerebral, carotid or vertebral arteries. For example: A patient is admitted for routine cataract extraction and the history and physical examination indicates weakness of the left arm. It is very important to note that even though this is an addenda change, and does not involve code changes, it has significant consequences for the coding professional.
However, if the admission is for rehabilitation a code from category V57, Care involving use of rehabilitation procedures is assigned as the principal diagnosis with an additional code from category 438. There is no other supporting documentation regarding this diagnosis. Final code assignment is based on physician documentation, so if there is conflicting or vague documentation, query the physician for clarification. When blood fails to get through to the affected parts of the brain, the oxygen supply is cut off and brain cells begin to die. Major risk factors include hypertension, smoking, and elevated cholesterol levels, but prompt treatment can decrease the complications and damage. The degree of impairment varies from case to case.