August 2012

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Coding Sequelae of Cerebrovascular Disease in ICD-10-CM

By Theresa A. Rihanek, MHA, RHIA, CCS

Sequelae are residual effects or conditions produced after the acute phase of an illness or injury has ended. Therefore there is no time limit on when a sequela code can be assigned. Residuals may be apparent early on such as in cerebral infarction, or they can occur months or years later. In ICD-9-CM, residual conditions were referred to as “late effects.” ICD-10-CM sequela replaces that terminology. Cerebrovascular disease sequelae include deficits such as aphasia, dysphagia, monoplegia, or hemiparesis that arise from any condition classifiable to categories I60-I67.

Coding of sequelae in ICD-10-CM generally requires two codes. The residual condition or nature of the late effect is sequenced first. An exception to this requirement is when the sequelae have been expanded to include the manifestation(s). Cerebrovascular sequelae codes have been expanded to include the manifestation, so require only one code for both the residual condition and the cause of the sequelae.

ICD-10-CM classifies sequelae of cerebrovascular disease in category I69. The subcategories delineate the sequelae by type of cerebrovascular disease. These subcategories include:

  • Sequelae of nontraumatic subarachnoid hemorrhage (I69.0-)
  • Sequelae of nontraumatic intracerebral hemorrhage (I69.1-)
  • Sequelae of other nontraumatic intracranial hemorrhage (I69.2-)
  • Sequelae of cerebral infarction (I69.3-)
  • Sequelae of other cerebrovascular diseases (I69.8-)
  • Sequelae of unspecified cerebrovascular diseases (I69.9-)

Assigning the correct sequela code requires proper use of the Alphabetic Index and validation of the selected code within the Tabular List. Under the main term, Sequelae, there are several subterms to direct users to category I69. Coders must carefully review these subterms such as disease, cerebrovascular; hemorrhage, intracerebral; hemorrhage, intracranial nontraumatic; hemorrhage, subarachnoid; infarction, cerebral; or stroke, not otherwise specified (NOS). Thorough review of the documentation will be necessary to determine the causal cerebrovascular disease that led to the sequela.

There are sequelae of cerebrovascular disease codes for hemiplegia/hemiparesis, monoplegia of upper limb, monoplegia of lower limb, and other paralytic syndromes. These codes classify whether the dominant or nondominant side is affected. A patient who is right-handed is regarded as right-side dominant and a patient who is left-handed is deemed left-hand dominant. When a right-handed patient experiences left upper limb paralysis following a stroke, the code designates “left non-dominant side” in the description.

Example 1: A patient was admitted for outpatient physical therapy for monoplegia of the left leg affecting the non-dominant side due to a spontaneous subarachnoid hemorrhage that occurred two weeks ago.

Assign I69.044, “Monoplegia of lower limb following nontraumatic subarachnoid hemorrhage affecting left non-dominant side,” as the first listed diagnosis for this encounter.

Rationale:  ICD-10-CM does not provide a category for care involving use of rehabilitation procedures, such as V57 in ICD-9-CM. In the case of cerebrovascular disease, it is the sequela that is being addressed. Since cerebrovascular disease codes combine the underlying condition and the type of sequela into one single code, only one code needs to be assigned.

Coding Guideline 1.C.6.a provides direction for situations in which the documentation does not include information regarding dominance or nondominance:

"Should the affected side be documented, but not specified as dominant or nondominant and the classification system does not indicate a default, code selection is as follows:

  • For ambidextrous patients, the default should be dominant
  • If the left side is affected, the default is non-dominant
  • If the right side is affected, the default is dominant."

Example 2: A patient presents for follow-up a month after suffering a cerebral infarction. The physician notes the patient is suffering from right-sided hemiplegia due to the infarction and recommends continued physical and occupational therapy.

Assign I69.351, "Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side."

Rationale: When the hemiplegia is stated as right sided, but not specified as dominant or nondominant, coding guidelines direct users to default to dominant.

Codes from category I69 may be used with acute codes from I60-I67 when the patient presents with a current cerebrovascular disease, and sequelae from an old cerebrovascular disease are also present.

Example 3: A patient presents with new right middle cerebral artery embolism and infarction causing aphasia. The patient suffered a ruptured cerebral aneurysm a year prior with residual oral phase dysphagia.

Assign I63.411, "Cerebral infarction due to embolism of right middle cerebral artery as the principal diagnosis.” Assign I69.091, “Dysphagia following nontraumatic subarachnoid hemorrhage," and R13.11, “Dysphagia, oral phase as secondary codes."

Rationale: The current infarction due to the middle cerebral artery embolism is the reason for admission. This is coded as acute, not as sequelae. A secondary diagnosis for aphasia is coded. In this case the patient also presents with sequela from a previous cerebrovascular disease. A ruptured cerebral aneurysm is classified to subarachnoid hemorrhage in ICD-10-CM. Use Index “Sequelae, hemorrhage, subarachnoid, dysphagia.” Instructional notes direct coders to assign an additional code for the type of dysphagia, if known.

Some patients do not experience any residual deficits following acute cerebrovascular disease. Code Z86.73, “Personal history of transient ischemic attack and cerebral infarction without residual deficits” is to be assigned as an additional code. An Excludes1 note is present at Z86.73 as well as at category I69. An Excludes1 note indicates that the two conditions may not be coded together. Therefore, do not assign Z86.73 in conjunction with codes from I69.

References
DeVault, K.,  A. Barta, and M. Endicott. ICD-10-CM Coder Training Manual:  Instructor’s Edition. Chicago, IL:  American Health Information Management Association, 2012.

Centers for Disease Control and Prevention. (2012). ICD-10-CM Official Guidelines for Coding and Reporting. Retrieved from: http://www.cdc.gov/nchs/data/icd10/10cmguidelines2012.pdf

Theresa Rihanek is a director of HIM solutions at AHIMA.

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