ICD 10 Codes for CVA with No Late Effects | What is a CVA Part 1

ICD 10 Codes for CVA with No Late Effects | What is a CVA Part 1


Alicia: Q: “If a physician dictates” and
this is another one those ones that’s a little confusing “that a patient recently
had a CVA with no late effects,” or now we would say residual or deficit, sequel,
“what would be the correct ICD-10 code?” A: I had to think about this, and quite honestly
when I went to explain this, I went off on a tangent because I love the disease process,
right? Laureen: You? No never. You’d never go off
on a tangent. [Laughs] Alicia: And then I went back here and I looked
it again, and I thought this really is quite a simple question and I’m making it more
than it needs to be. So, it is important to note that she states that this question is
coming from a rehabilitation facility or aftercare services is what the scenario is coming from
and that’s why she’s asking. The quick answer is, you have a couple choices,
and the couple choices is you can code it as a history, Z86.73, or you can code it as
unspecified sequelae I69.30. Now, the long answer; when you look at those two codes,
always err on the side of caution here, but let’s look at this and read them. Personal
history, pertinent, because if something is a personal history code, they’re not being
treated for that code anymore. Now, that’s important to remember. Just with breast
cancer, that’s something that is debated a lot. But, a personal history of a TIA or
a cerebral infarction, CVA, without residual deficits. A personal history of prolonged
reversible ischemic, neurological deficit or Personal history of a stroke, otherwise
specified without residual deficits, that’s what we got here, right? It just says that
they have a recent CVA with no residual deficits, so that’s a choice. But, for that to work you cannot have any
more treatment for that diagnosis. Now, that doesn’t mean you can’t use that and that
may not be why the person was sent or it’s going to be staying in this facility. So,
what you have to ask yourself is why are they in the facility? Are they in the facility
because they had a CVA and they need therapy and so on and so forth? Well, then, personal
history is not a good choice, is it? Because they’re getting treatment for that. Can
they have a recent CVA with no deficits and still need to be in the facility? Absolutely,
there are all kinds of reason. Can it just be one
diagnosis in the list of several? Absolutely. So, I am inclined to think that without having
more information, just a broad statement like that, it probably is a personal history. But
can you code something as a personal history without the doctor documenting that is a personal
history? You have to define that; is it defined here? Is it a personal history of a stroke,
not otherwise specified without residual deficits or is it unspecified sequelae, late effect
of a CVA. The thing that gets you here is this comment:
Category I69, which is the CVA area, is to be used to indicate conditions between this
range, I60-I67, as causes of the sequelae. The ‘sequelae’ include conditions specified
as such or as residual which may occur at any time after the onset of the causal condition.
Again, I’m inclined to say we’ve got a Z code here, a history code, but without all
of the documentation. You really can’t make a clear statement that this is the code.

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