CVA and TIA?
When coding cerebral vascular accidents (CVA) and transient ischemic attacks (TIA), it is important to know the difference between the 2 diagnoses as well as the different types of CVA.
While both a CVA and TIA are caused by blockages to the arteries of the brain, a CVA is a more serious condition and can cause permanent brain cell damage and lasting deficits. The deficits last longer than 24 hours. A TIA is a temporary condition and the normal function of the patient returns quickly with little or no damage to the brain cells. The deficits last less than 24 hours.
A CVA can be caused by an embolism, thrombus or hemorrhage of the brain. (the brain hemorrhage is non-traumatic. Traumatic brain hemorrhages are not CVAs). Documentation is key and the Provider may have to be queried to clarify the type or site of the CVA. The vessel involved may be cerebral or precerebral and it may be an occlusion, stenosis, embolism, thrombus or hemorrhage.
Mistaking a transient ischemic attack (TIA) to be synonymous with a stroke.
Common indicating diagnosis that may or may not accompany a TIA diagnosis is a “stroke alert.” A stroke alert may be included as a supplementary diagnosis when the patient’s signs and symptoms are indicative of a possible stroke. However, the impression of the dictation report will have final say as to whether a stroke is revealed in the imaging scan. If not, there’s a possibility that the patient’s symptoms are the result of a TIA, but without a definitive TIA diagnosis, you should code only the signs and symptoms.
TIA diagnosis, unlike a stroke diagnosis, can be coded from the indication. Preliminary TIA diagnoses are often made based on a patient’s presentation of signs and symptoms. Follow-up imaging is then ordered to determine the underlying cause of the TIA.
Reporting an old, incidental cerebral infarction as a secondary diagnosis, use code Z86.73 Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits.
If a patient is NOT EXPERIENCING A CURRENT CEREBROVASCULAR ACCIDENT (CVA) and has no residual or late effect from a previous CVA, Z86.73 (personal history of transient ischemic attack, and cerebral infarction without residual deficits) should be assigned. A patient experiencing no residual effects from a previous stroke should NEVER be assigned a current stroke code.
In order to accurately code sequelae (late effect) of cerebrovascular disease, the side of the body affected should be clearly documented in the medical record.
Category I69, Sequelae of Cerebrovascular diseaseCategory I69 is used to indicate conditions classifiable to categories I60-I67 as the causes of sequela (neurologic deficits), themselves classified elsewhere. These “late effects” include neurologic deficits that persist after initial onset of conditions classifiable to categories I60-I67. The neurological deficits caused by cerebrovascular disease may be present from the onset or may arise at any time after the onset of the condition classifiable to categories I60-I67.
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When coding cerebral vascular accidents (CVA) and transient ischemic attacks (TIA), it is important to know the difference between the 2 diagnoses as well as the different types of CVA.
While both a CVA and TIA are caused by blockages to the arteries of the brain, a CVA is a more serious condition and can cause permanent brain cell damage and lasting deficits. The deficits last longer than 24 hours. A TIA is a temporary condition and the normal function of the patient returns quickly with little or no damage to the brain cells. The deficits last less than 24 hours.
A CVA can be caused by an embolism, thrombus or hemorrhage of the brain. (the brain hemorrhage is non-traumatic. Traumatic brain hemorrhages are not CVAs). Documentation is key and the Provider may have to be queried to clarify the type or site of the CVA. The vessel involved may be cerebral or precerebral and it may be an occlusion, stenosis, embolism, thrombus or hemorrhage.
Mistaking a transient ischemic attack (TIA) to be synonymous with a stroke.
Common indicating diagnosis that may or may not accompany a TIA diagnosis is a “stroke alert.” A stroke alert may be included as a supplementary diagnosis when the patient’s signs and symptoms are indicative of a possible stroke. However, the impression of the dictation report will have final say as to whether a stroke is revealed in the imaging scan. If not, there’s a possibility that the patient’s symptoms are the result of a TIA, but without a definitive TIA diagnosis, you should code only the signs and symptoms.
TIA diagnosis, unlike a stroke diagnosis, can be coded from the indication. Preliminary TIA diagnoses are often made based on a patient’s presentation of signs and symptoms. Follow-up imaging is then ordered to determine the underlying cause of the TIA.
Reporting an old, incidental cerebral infarction as a secondary diagnosis, use code Z86.73 Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits.
- Early hyperacute: Zero to six hours
- Late hyperacute stroke: Six to 24 hours
- Acute stroke: 24 hours to one week
- Subacute stroke: One to three weeks
- Chronic stroke: Greater than three weeks
| ICD-10 Code Category | ICD-10 Description |
| I60-I62 | Non-traumatic intracranial hemorrhage |
| I63 | Cerebral infarctions |
| I65-I66 | Occlusion/stenosis of cerebral and precerebral vessels without infarction |
| I67-I68 | Other cerebrovascular diseases |
| I69 | Sequelae of cerebrovascular disease (late effect) |
- Code category I60-I62 specifies the location or source of a hemorrhage as well as its laterality
- Code category I63 specifies the following:
- Cause of the ischemic stroke
- Specific location and laterality of the occlusion
- Code category I65-I66 requires the coder to be able to determine whether an occlusion or stenosis involves the precerebral arteries or the cerebral arteries
- Precerebral arteries include:
- Vertebral artery
- Basilar Artery
- Carotid Artery
- Cerebral arteries include:
- Anterior cerebral artery
- Middle cerebral artery
- Posterior cerebral artery
- Precerebral arteries include:
- Code category I67-I68 specifies other cerebrovascular diseases and cerebrovascular disorders in diseases classified elsewhere
- Code category I69 (Sequelae of cerebrovascular disease) specifies the type of stroke that caused the sequelae (late effect) as well as the residual condition itself. Codes from Category I69 also identify whether the dominant or non-dominant side is affected
If a patient is NOT EXPERIENCING A CURRENT CEREBROVASCULAR ACCIDENT (CVA) and has no residual or late effect from a previous CVA, Z86.73 (personal history of transient ischemic attack, and cerebral infarction without residual deficits) should be assigned. A patient experiencing no residual effects from a previous stroke should NEVER be assigned a current stroke code.
In order to accurately code sequelae (late effect) of cerebrovascular disease, the side of the body affected should be clearly documented in the medical record.
Category I69, Sequelae of Cerebrovascular diseaseCategory I69 is used to indicate conditions classifiable to categories I60-I67 as the causes of sequela (neurologic deficits), themselves classified elsewhere. These “late effects” include neurologic deficits that persist after initial onset of conditions classifiable to categories I60-I67. The neurological deficits caused by cerebrovascular disease may be present from the onset or may arise at any time after the onset of the condition classifiable to categories I60-I67.
Coding Guidelines
- Documentation of unilateral weakness in conjunction with a stroke is considered by the ICD to be hemiparesis/hemiplegia due to the stroke and should be reported separately. Hemiparesis is not considered a normal sign or symptom of stroke and is always reported separately.
- Code Sequela of Cerebrovascular Disease/Stroke (ICD-10 code I69*) anytime post diagnosis of any condition classifiable to ICD-10 codes I60 – I67. a. Providers must link the deficit with the stroke to be able to comply with the sequela code. b. Use codes from category I69 to specify the residual condition and the affected side of the patient (dominate or non-dominate).
- Codes from category I69, Sequelae of cerebrovascular disease, that specify hemiplegia, hemiparesis and monoplegia identify whether the dominant or nondominant side is affected. 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.
- If the patient’s dominant side is not documented, assume the left side is non-dominant, except for ambidextrous patients. In ambidextrous patients, assume the affected side is dominant.
- Report any and all neurological deficits of a cerebrovascular accident that are exhibited anytime during a hospitalization, even if the deficits resolve before the patient is released from the hospital.
- Once the patient has completed the initial treatment for stroke and is released from acute care, report deficits with codes from I69 Sequelae of cerebral infarction. Neurologic deficits may be present at the time of the acute event or may arise at any time after the condition reported with I60-I67.
- If the provider is not specific in recording the site of a stroke or infarction, it is permissible for coders to use the accompanying CT scans or other radiological reports to report the specific anatomic site.
- Codes I60-I69 should never be used to report traumatic intracranial events.
- Normally, do not report codes from I80-I67 with codes from I69. However, if the patient has deficits from an old cerebrovascular event and is currently having a new cerebrovascular event, both may be reported.
- If a patient has a history of a past cerebrovascular event and has no residual sequelae, report Z86.73 Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits.
- If a patient is diagnosed with bilateral nontraumatic intracerebral hemorrhages, report I61.6 Nontraumatic intracerebral hemorrhage, multiple localized. For bilateral subarachnoid hemorrhage, assign a code for each site. Categories I65 and I66 have unique codes for bilateral conditions.
- Also code any documented atrial fibrillation, CAD, diabetes, or hypertension as these comorbidities are stroke risk factors.
- Acute Ischemic Stroke (ICD-10 code I63.*) should not be coded from an outpatient setting because confirmation of the diagnosis should be determined by diagnostics studies, such as non-contrast brain CT or brain MRI, which would be ordered in an emergency room and/or inpatient setting.
- ICD-10 Code Category I63.* generally requires causation and location of the stroke.a. Non-specific ICD-10 codes I63.8 and I63.9 should not be used in an outpatient setting and should be avoided during an inpatient setting where site and cause should be determined by diagnostic testing.
- Unconfirmed Stoke Diagnoses in the outpatient setting: Do not code diagnoses documented as probable, suspected, likely, questionable, possible, still to be ruled out, or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reasons for the visit.
- History of Stroke (ICD-10 code Z86.73) a. The patient is seen in the outpatient setting after a confirmed diagnosis of a stroke, currently not experiencing a CVA, and shows no residual deficits. b. A diagnosis of a transient ischemic attack (TIA) was made and has been resolved.
- Transient ischemic attack (TIA)a. When a TIA is diagnosed, a separate code is used (G45.9). This can be referred to as a “ministroke” but should be considered separate from coding for a cerebral infarct.
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