July 2013

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Clinical Documentation Improvement: Stroke Case Study

By the AHIMA CDI Workgroup

The patient was admitted into the emergency department (ED) with complaints of change in mental status, slurred speech, and weakness and numbness to the left side. The onset of the symptoms was sudden, beginning four to six hours ago. The patient has a history of hypertension, transient ischemic attack (TIA), hyperlipidemia, and coronary artery disease. Vital signs in the ED: 36.7-74-20 217/109. The patient received 325 mg of aspirin by mouth and 5 mg of Labetalol intravenously. A CT scan of the brain showed no acute findings. If signs or symptoms persist, CT scan may be repeated in 12 to 24 hours, or an MRI may be ordered to further evaluate. 

The patient arrived to the nursing unit for evaluation of TIA. The patient was given 325 mg of aspirin, 25 mg of Lopressor, and neurology consulted. The patient’s symptoms continued, with numbness and weakness to left side and mental status change. An MRI was ordered which showed cerebral infarct. TIA has been ruled out and patient now admitted with cerebrovascular accident (CVA). A neurological consult confirms the patient has left sided weakness with right sided CVA infarction.

ICD-9-CM Code Assignment
434.91  Unspecified cerebral artery occlusion with cerebral infarction
780.79  Malaise and fatigue
401.9    Hypertension, unspecified
MS-DRG 066 Intracranial Hemorrhage or Cerebral Infarction without CC/MCC

ICD-9-CM Documentation Improvement: Possible Queries

  1. Was the underlying cause of the CVA a traumatic injury or nontraumatic cause?
  2. What was the CVA due to:

    a. Aneurysm
    b. Embolic (with/without hemorrhage)
    c. Hemorrhage
    d. Ischemic
    e. Occlusion
    f. Paralytic
    g. Thombotic
    h. TIA
    i. Unspecified Cause
    j. Other

  3. Identify the cause of the left-sided weakness
  4. Identify the type of hypertension

Stroke Core Measure Documentation
Physician should document a contraindication if the following are not prescribed:

  1. Antithrombotic Therapy
  2. Statin
  3. Rehab Consultation
  4. Anticoagulant, if patient has a history of atrial fibrillation

ICD-10-CM Code Assignment
I63.9    Cerebral infarction, unspecified
R53.1   Weakness
I10       Essential (primary) hypertension
MS-DRG 066 Intracranial Hemorrhage or Cerebral Infarction without CC/MCC

ICD-10-CM Documentation Improvement: Possible Queries

1. Identify site of the occlusion:
a. Cerebral
i. Anterior
ii. Middle
iii. Posterior
b. Cerebellar
c. Other (please specify): __________________
d. Unspecified cerebral artery
2. Identify laterality of the occlusion:

a. Right
b. Left
c. Unspecified

3. With infarction identify the etiology of the occlusion:

a. Embolic
b. Thrombotic
c. Other (please specify): __________________
d. Unspecified Cause

4. Cause of the patient's left-sided weakness

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