ICD-9-CM and CPT coding update
By Therese M. Jorwic, MPH, RHIA, CCS, CCS-P
Every year, about 795,000 people in the U.S. have a stroke. About 75% of those are first strokes; the rest are repeat strokes.
Most- an estimated 87%- are ischemic, where a blood clot blocks a blood vessel to the brain. The others are hemorrhagic, or bleeding strokes.
The severity of a stroke depends on the part of the brain that is affected and how long the blood flow is restricted. And severity is usually high. In the U.S., stroke is the leading cause of serious long-term disability.
Coding with today’s codes
With our current ICD-9-CM codes, ischemic stroke is found in the chapter covering diseases of the circulatory system. The codes begin at 434 for occlusion of the cerebral arteries, and there are fourth digits to show the type of occlusion:
434.0 – cerebral thrombosis
434.1 – cerebral embolism
434.9 – unspecified cerebral artery occlusion
Both thrombosis and embolism are obstructions within the artery. The difference is that a thrombus is a mass of platelets, fibrin, or other components of the blood that forms within the vessel, while an embolus is an actual clot that is carried to the site by the bloodstream.
These codes also have fifth digits – 0 for no mention of cerebral infarction, and 1 for cerebral infarction. The infarction is the stroke, or the tissue death that occurs when the blood supply to the brain is interrupted.
(If the documentation shows only cerebrovascular accident, or CVA, with no other information, the default code is 434.91, or unspecified with cerebral infarction. Code 436 is for acute but ill defined cerebrovascular disease. However, a note there says to us 431.91 for stroke.)
RESIDUAL EFFECTS
What about the residual effects a stroke can cause? For those, go to category 438, which covers late effects, or sequelae of cerebrovascular disease.
So suppose the patient earlier had a stroke and is now being treated for dysphasia, or impaired speech. The code is 438.12. Use that code even if the visit is due to some diagnosis other than stroke, because the dysphasia could make the care more complicated.
V CODES
There are also two V codes to use with strokes.
The first is V12.54, which shows a personal history of stroke with no residual effects. It’s an important code to use, because a patient who has had a stroke is at relatively high risk of having another.
The other is V45.88, and it is used only for the hospital care. It shows that tPA- or clot buster drug- was begun in one facility within 24 hours before the patient was admitted to the current facility.
Coding it all after Oct. 1, 2015
With the new ICD-10-CM codes, cerebrovascular disease is covered in categories I60 through I69.
While ICD-9-CM has only a fifth digit to show the presence of stroke, in ICD-10-CM, stroke, or cerebral infarction, has an entire category, which is I63.
As a result, the new codes can give more information. For example, the fourth character shows whether infarction is due to
- I63.0 – thrombosis of precerebral arteries
- I63.1 – embolism of precerebral arteries
- I63.2 – unspecified occlusion of precerebral arteries
- I63.3 – thrombosis of cerebral arteries
- I63.4 – embolism of cerebral arteries
The new codes also allow for more detail on the vessels involved and show laterality, or the side of the body where the stroke occurs.
Thus, it’s possible to give a complete picture. For example, I63.312 shows cerebral infarction due to thrombosis of left middle cerebral artery.
RESIDUAL EFFECTS
As for residual effects of stroke, ICD-10 uses the term sequelae instead of late effects.
Other than that, the old and new codes are much the same. In ICD-10, the main category is I69.3 (sequelae of cerebral infarction), and there are additional characters to identify the type of disability. For example, I69.321 shows dysphasia following cerebral infarction.
The main difference here is in the laterality.
The old codes show only whether the patient’s dominant or nondominant side is affected. The new codes show dominant and nondominant but then go a step further and show whether the side is left or right. For example, under I69.35 (hemiplegia and hemiparesis) are characters to show if the affected side is right dominant, left dominant, right nondominant, left nondominant, or unspecified.
What if the documentation does not say if the side is dominant or not? The guides say to assume that right or ambidextrous is dominant and left is nondominant.
V CODES BECOME Z CODES
Instead of V codes, ICD-10 has Z codes.
The code for personal history of stroke with no residual effects is Z86.73. And the code for tPA administration at another hospital is Z92.82.
Therese M. Jorwic, MPH, RHIA, CCS, CCS-P, is assistant professor of health information management at the University of Illinois at Chicago and senior consultant for MC Strategies in Atlanta.
