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.