This page addresses follow-up questions and additional information pertinent to our webinar
ICD-10-CM Stroke Coding: The Why Behind the Codes.
** The coding information and guidance are valid at the time of publishing. Learners are encouraged to research
subsequent official guidance in the areas associated with the topic as they can change rapidly.

Q: Can you code arteriosclerosis of the cerebral or precerebral arteries along with an infarction code? In coronary artery disease with myocardial infarction (MI), both can be coded. Is this the same?
A: No, stroke coding is different than MI coding. Once cerebral arteriosclerosis progresses to infarction, only a code from category I63 for the infarction is reported. There is an Excludes1 note that prevents coding both conditions together.

Q: Can you use a code for an old CVA with a code for a current stroke?
A: Yes, if a patient has a history of stroke and is presenting with an acute stroke, a code for the old CVA – either a code from category I69 for sequelae or the Z code for history of stroke without residuals – can be coded with an acute stroke code. This is supported by Excludes2 notes throughout categories I60-I63.

Q: What is the timeframe for reporting a sequela of CVA? If a patient is transferred from an acute care hospital to rehab for continued care for the stroke, is it coded as acute or a sequela?
A: There is no time limit on when a stroke can be considered a sequela. When the encounter is for a rehab or other post acute care for the continued treatment of an acute stroke, the post acute care facility should assign a code from category I69 for sequela. There is a lot of valuable information about coding in the post acute care setting in Coding Clinic, Fourth Quarter 2012, page 90.

Q: When you look up “Hemiplegia” in the index, it gives subterms for embolic (I63.4-), thrombotic (I63.3-), and following CVA (various codes in category I69). What is the correct way to report hemiplegia in a stroke?
A: Hemiplegia is a neurological deficit that commonly accompanies a stroke. When hemiplegia is caused by an acute stroke, assign the appropriate code from category I63 to specify the type of infarction (e.g., embolic, thrombotic) followed by a code from subcategory G81.9 to specify the presence of hemiplegia and the side affected. Do not assign codes in category I69 for acute stroke, as those codes are for sequelae. If the patient has sequelae of a stroke with residual hemiplegia, assign the appropriate code from category I69. These codes include hemiplegia as a component of code assignment and no additional code from subcategory G81.9 is needed.

4/12/24 Q: In the last case study (#4) of the webinar why didn’t the aphasia get coded? (Neurological deficits due to stroke are coded, even when they resolve by discharge)
A: We did not code aphasia since it is documented as remote and having been resolved within 24 hours of onset. Since this was a resolved neurological deficit related to a previous encounter, it was not coded. However, the patient did arrive for the current encounter with “sudden onset word finding and word phonation difficulties,” which is aphasia, so it should have been coded for this case example.

4/12/24 Q: How would you code a thromboembolic stroke? (thrombus and embolism code differently)
A: Assign a code for embolic stroke when thromboembolic stroke is documented. A thrombotic stroke occurs when a blood clot forms in an artery. An embolic stroke is the result of a piece of clot or other material (e.g., plaque) breaking loose and traveling to another artery where it causes occlusion. In the case of a thromboembolic stroke, it is most important to capture the embolic nature of the infarction.

4/12/24 Q: What if the specific artery isn’t specified, but the site of the brain is? Can you code a stroke for the artery that anatomically supplies that site? (ie Occipital lobe is supplied by the posterior cerebral artery)
A: We do not recommend coding a stroke to a specific artery when only the site of the brain is documented. While it is true that the posterior cerebral artery (PCA) supplies blood to the occipital lobe, the basilar (precerebral) artery feeds into PCA. A stroke in the occipital lobe could be caused by occlusion in either the basilar artery or PCA. Instead, we recommend working with providers to educate them on documenting the specific artery rather than (or in addition to) the lobe affected by the stroke.

4/12/24 Q: Would you code headache and visual deficits if those are the deficits experienced upon presentation? (It is appropriate to code residuals from a new CVA when the residual is still present at the time of discharge)
A: Headache is a symptom of stroke, not a neurological deficit, so headache would be considered integral and not coded separately per guideline I.B.5. “Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification.” If the patient has a visual deficit, it may be coded in addition to the stroke code.

In the following example, we recommend assigning code I63.12 for cerebral infarction due to embolism of the basilar artery. Although documentation also notes that the stroke involved the “anterior circulation,” this is not a specific artery. “Anterior circulation” is not the same as the anterior cerebral artery; it simply refers to the arteries as a whole affecting the front (anterior) portion of the brain. It is also important not to confuse lobes with similarly named arteries. In this example, the MRI results refer to the portions of the brain affected, not specific arteries; infarction of the right cerebellar hemisphere is not synonymous with an infarction of the cerebellar artery. Since there is a documented 50% stenosis in the internal carotid artery (ICA) and the ICA is part of the anterior circulation, you may choose to query the provider to see if the infarction involved the ICA as well. If so, code I63.131, Cerebral infarction due to embolism of right carotid artery, would also be assigned.

• DS: right thromboembolic small ischemic infarcts (involving occipital, cerebellar temporal and thalamic regions). 50% short segment stenosis of proximal right internal carotid artery
• Consult: Diffuse thromboembolic stroke in the basilar and anterior circulation. right carotid artery stenosis mild to moderate.
• MRI: consistent with small regions of infarction within the right cerebellar hemisphere, right thalamus and along the cortex within the right occipital lobe, and within the cortex involving the medial right temporal lobe.
• CT angio: 50% short-segment stenosis of the proximal right internal carotid artery

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