APPENDIX A NEUROLOGIST S GUIDE TO USING ICD-9-CM CODES FOR CEREBROVASCULAR DISEASES INTRODUCTION

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1 APPENDIX A NEUROLOGIST S GUIDE TO USING ICD-9-CM CODES FOR CEREBROVASCULAR DISEASES INTRODUCTION ICD-9-CM codes for cerebrovascular diseases is not user friendly. This presentation is designed to assist neurologists in choosing proper ICD-9-CM codes by using a cross-walk to more familiar terms. The user is strongly encouraged to re-refer to ICD-9-CM Volume 1 after choosing a code here to be sure there are no other instructions which would indicate using a different code for this situation. THIS GUIDE HAS NOT BEEN OFFICIALLY ACCEPTED BY CMS OR THE NATIONAL CENTER FOR HEALTH STATISTICS. IT IS POSSIBLE THAT CERTAIN MEDICARE CARRIERS OR OTHER THIRD PARTY REVIEWERS MAY DISAGREE WITH THESE CODING CHOICES. Acute Inpatient Coding: Use the appropriate acute stroke codes (see appendix 1). Add the manifestations if possible, or consider adding risk factors (if addressed). Outpatient coding: If the patient is seeing you for the first time for a stroke as an outpatient, and your consultation or new visit centers on managing or working up the acute event, then use the acute stroke codes. If, on the other hand, you are managing a stroke patient who has already had a workup and/or is being seen in followup of the acute event, then use the late effects codes (see appendices 2 & 3) if you are following the sequelae. It is not unreasonable to use a risk factor code if that is what is addressed in the visit, but it is more likely that these will be used as secondary codes (if addressed in the visit).

The user is strongly encouraged to re-refer to ICD-9-CM Volume 1 after choosing a code here to be sure there are no other instructions which would indicate using a different code for this situation.

2 Appendix 1 DIAGNOSIS SUGGESTED ICD-9-CM CODE Transient cerebral ischemia and related syndromes (Note these are four digit codes) Vertebral artery TIA or Transient cerebral ischemia, Vertebral syndrome artery syndrome Basilar artery TIA or syndrome Transient cerebral ischemia, Basilar artery syndrome Vertebrobasilar (artery)tia or Transient cerebral ischemia, syndrome Vertebrobasilar artery syndrome Carotid artery TIA or syndrome Other specified transient cerebral ischemia TIA in any other Other specified transient cerebral cerebrovascular territory ischemia (Middle cerebral, Posterior cerebral, Anterior cerebral, etc) TIA without territory specified Unspecified transient cerebral ischemia Amaurosis fugax Retinal vascular occlusion, Transient arterial occlusion Transient global amnesia Transient global amnesia Occlusion or of precerebral (extracranial) arteries WITHOUT infarction (stroke) (Note these are five digit codes) Basilar artery occlusion or Vertebral artery occlusion or Carotid artery occlusion or Multiple and bilateral precerebral (extracranial) artery occlusion or Precerebral (extracranial) artery occlusion or without territory specified Occlusion and of precerebral arteries, Basilar artery, without mention of infarction Occlusion and of precerebral arteries, Vertebral artery, without mention of infarction Occlusion and of precerebral arteries, Carotid artery, without mention of infarction Occlusion and of precerebral arteries, Multiple and bilateral arteries, without mention of infarction Occlusion and of precerebral arteries, unspecified precerebral artery, without mention of infarction Occlusion or of precerebral (extracranial) arteries WITH infarction (stroke) (Note these are five digit codes)

3 Transient cerebral ischemia, syndrome Vertebrobasilar artery syndrome Carotid artery TIA or syndrome 435.8 Other specified transient cerebral ischemia TIA in any other 435.

3 Basilar artery occlusion or Vertebral artery occlusion or Carotid artery occlusion or Multiple and bilateral precerebral artery occlusion or Precerebral artery occlusion or without territory specified Occlusion and of precerebral arteries, Basilar artery, with infarction Occlusion and of precerebral arteries, Vertebral artery, with infarction Occlusion and of precerebral arteries, Carotid artery, with infarction Occlusion and of precerebral arteries, Multiple and bilateral arteries, with infarction Occlusion and of precerebral arteries, unspecified precerebral artery, with infarction Occlusion or of intracerebral arteries WITH infarction (stroke) (Note these codes have five digits) Middle cerebral artery Occlusion of cerebral arteries, Middle cerebral artery Occlusion of cerebral arteries, Anterior cerebral artery Occlusion of cerebral arteries, Anterior cerebral artery Occlusion of cerebral arteries, Posterior cerebral artery Occlusion of cerebral arteries, Posterior cerebral artery Occlusion of cerebral arteries, Any other intracerebral artery Occlusion of cerebral arteries, Any other intracerebral artery Occlusion of cerebral arteries, Cerebral thrombosis (no artery Occlusion of cerebral arteries, mentioned) Cerebral thrombosis, with cerebral infarction Cerebral embolism, (no artery Occlusion of cerebral arteries, mentioned) Cerebral embolism, with cerebral infarction Lacunar infarction (stroke) Cerebral artery occlusion, unspecified, with cerebral infarction Cerebral infarction (stroke) Cerebral artery occlusion, with no vascular territory unspecified, with cerebral infarction specified NOTE THAT THE DEFAULT CODE FOR ISCHEMIC STROKE IS:

11 Occlusion and of precerebral arteries, Carotid artery, with infarction 433.31 Occlusion and of precerebral arteries, Multiple and bilateral arteries, with infarction 433.

4 Cerebral artery occlusion, unspecified, with cerebral infarction If the only term documented is Stroke, then use this code. Use this code when the vascular territory is unknown. Because of the lack of specificity of this code please upgrade to a more specific code as soon as the vascular territory and mechanism of stroke are known. Hemorrhage (bleed) Nontraumatic subarachnoid hemorrhage Intracerebral (intraparenchymal) hemorrhage Intraventricular hemorrhage Nontraumatic subdural hemorrhage Nontraumatic extradural (epidural) hemorrhage Intracranial hemorrhage without further site or type specification 430 Subarachnoid hemorrhage 431 Intracerebral hemorrhage 431 Intracerebral hemorrhage Subdural hemorrhage Nontraumatic extradural hemorrhage Unspecified intracranial hemorrhage Other cerebrovascular diagnoses Nonruptured cerebral Cerebral aneurysm, nonruptured aneurysm, any territory Cerebral atherosclerosis Cerebral atherosclerosis (useful when attributing a manifestation such as vascular dementia) Diffuse cerebral ischemia Other generalized ischemic (nonatherosclerotic) cerebrovascular disease Hypertensive encephalopathy Hypertensive encephalopathy Cerebral arteritis (vasculitis) Cerebral arteritis Add code for the primary disease if present! Moyamoya disease Moyamoya disease Venous sinus thrombosis Nonpyogenic thrombosis of (noninfectious) intracranial venous sinus Infectious (pyogenic) venous 325 Phlebitis and thrombophlebitis of sinus phlebitis or intracranial venous sinuses. thrombophlebitis Binswanger s disease Use two codes: Other generalized ischemic cerebrovascular disease Presenile dementia with delusional features Carotid artery dissection Dissection of carotid artery

Hemorrhage (bleed) Nontraumatic subarachnoid hemorrhage Intracerebral (intraparenchymal) hemorrhage Intraventricular hemorrhage Nontraumatic subdural hemorrhage Nontraumatic extradural (epidural)

5 Vertebral artery dissection Dissection of other artery, or artery not named. Cerebral amyloid angiopathy Dissection of vertebral artery Dissection of other artery Other and ill-defined cerebrovascular disease Eponyms The codes indicated for use here by the index of ICD-9-CM are not compatible with the specificity of the vascular territory. Please strongly consider coding the vascular territory of infarction instead! Claude syndrome Multiple cranial nerve palsies Foville syndrome Other specified paralytic syndrome Wallenburg syndrome 436 Acute,, but ill-defined cerebrovascular disease Weber syndrome (Weber Other specified paralytic syndrome Gubler) (Weber-Leyden) Millard-Gubler Other specified paralytic syndrome Appendix 2: Example Late effects codes are used to describe conditions that occur at any time after the acute event. Use them for inpatient or outpatient care subsequent to the initial inpatient admission or outpatient evaluation. Example: Stroke: Patient is right handed admitted for left hemisphere stroke with aphasia and flaccid right hemiparesis. Code during the acute admission: Cerebral artery occlusion, unspecified Flaccid hemiplegia, affecting dominant side Aphasia Code after the acute admission: Late effects of cerebrovascular disease, Hemiplegia affecting dominant side Late effects of cerebrovascular disease, Aphasia Appendix 3: Late Effects Codes Cognitive defects Speech and language deficit, unspecified Aphasia Dysphasia Other speech and language deficits Hemiplegia/hemiparesis affecting

Please strongly consider coding the vascular territory of infarction instead! Claude syndrome 352.6 Multiple cranial nerve palsies Foville syndrome 344.

6 unspecified side Hemiplegia/hemiparesis affecting dominant side Hemiplegia/hemiparesis affecting nondominant side Monoplegia/monoparesis of upper limb affecting unspecified side Monoplegia/monoparesis of upper limb affecting dominant side Monoplegia/monoparesis of upper limb affecting nondominant side Monoplegia/monoparesis of lower limb affecting unspecified side Monoplegia/monoparesis of lower limb affecting dominant side Monoplegia/monoparesis of lower limb affecting nondominant side Other paralytic syndrome: Use additional code to identify that Syndrome such as: Locked in state (344.81) Quadriplegia/quadriparesis ( ) Other paralytic syndrome affecting unspecified side Other paralytic syndrome affecting dominant side Other paralytic syndrome affecting nondominant side Other paralytic syndrome, bilateral Alterations of sensation: Use additional code to identify the altered sensation Disturbances of vision: Use additional code to identify visual disturbance Apraxia Dysphasia Facial weakness or droop Ataxia Vertigo Other late effects of cerebrovascular disease: Use additional code to identify the late effect Unspecified late effects of cerebrovascular disease

32 affecting nondominant side Monoplegia/monoparesis of lower limb 438.40 affecting unspecified side Monoplegia/monoparesis of lower limb 438.

Stroke Coding Issues Presentation to: NorthEast Cerebrovascular Consortium

Stroke Coding Issues Presentation to: NorthEast Cerebrovascular Consortium October 30, 2008 Barry Libman, RHIA, CCS, CCS-P President, Barry Libman Inc. Stroke Coding Issues Outline Medical record documentation