Diagnosis Code Tip Sheet: /CVA and Sequela

Documentation Considerations Diagnosis Considerations  Document vessel affected:  Active stroke is only coded while in a hospital setting  Code for residual effects when being seen for follow-up (hemiplegia, o Precerebral Cerebral , , etc.) o  Code for “history of stroke” if patient has no o Cerebellar  Document residual findings of the stoke with treatment plant and follow- residual effects from the stroke up care I69.332 of upper limb following CI affecting left dominant side  Identify acuity of event (acute, healed, residual effects or sequelae) Monoplegia of upper limb following CI affecting non-dominant side Stroke without Residual Deficits I69.333 I69.334 Monoplegia of upper limb following CI affecting left non-dominant side Z86.73 Personal history of CVA with no residual deficits Monoplegia of upper limb following CI affecting unspecified side Sequela of Cerebral Infarction I69.339 I69.30 Unspecified sequelae of CI I69.341 Monoplegia of lower limb following CI affecting right dominant side Monoplegia of lower limb following CI affecting left dominant side I69.310 Attention and concentration deficit following CI I69.342 I69.311 Memory deficit following CI Monoplegia of lower limb following CI affecting right non-dominant I69.343 side I69.312 Visuospatial deficit and spatial neglect following CI I69.344 Monoplegia of lower limb following CI affecting left non-dominant side I69.313 Psychomotor deficit following CI I69.349 Monoplegia of lower limb following CI affecting unspecified side I69.314 Frontal lobe and executive function deficit following CI I69.351 Hemiplegia & hemiparesis following CI affecting right dominant side I69.315 Cognitive social or emotional deficit following CI I69.352 Hemiplegia & hemiparesis following CI affecting left dominant side Other symptoms and signs involving cognitive functions I69.318 following CI Hemiplegia & hemiparesis following CI affecting right non-dominant I69.353 side Unspecified symptoms and signs involving cognitive functions I69.319 following CI Hemiplegia & hemiparesis following CI affecting left non-dominant I69.354 side I69.320 Aphasia following CI I69.359 Hemiplegia & hemiparesis following CI affecting unspecified side I69.321 Dysphasia following CI Other paralytic syndrome following CI affecting right dominant side I69.322 Dysarthria following CI I69.361 I69.323 Fluency disorder following CI Other speech and language deficits following CI I69.328 Monoplegia of upper limb following CI affecting right I69.331 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. 1

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 Other paralytic syndrome following CI affecting left non-dominant side I69.364 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 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 I69.1X = Sequelae of nontraumatic 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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