Neurology Stroke Clinic ICD-10 documentation
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1 Neurology Stroke Clinic documentation Seven key impacts to documentation 1. Disease or disorder site 2. Acuity and/or encounter status of treatment 3. Etiology, causative agent, or type and injury/ poisoning cause, intent, activity at the time of the event and place event occurred 4. Underlying and associated conditions 5. Manifestations 6. Complications or adverse events 7. Supporting info such as lab values or socioeconomic key impacts to documentation Most commonly used diagnoses Name Name Acute, but ill-defined, Alterations of sensations as late effect of Aphasia as late effect of 436 I67.89 Other Refer to 7 key impacts of Documentation I Other sequelae following unspecified I Aphasia following nontraumatic I Aphasia following nontraumatic I Aphasia following other nontraumatic intracranial hemorrhage I Aphasia following cerebral infarction I Aphasia following other I Aphasia following unspecified 1
2 Name Name Apraxia as late effect of Ataxia as late effect of Cerebral aneurysm, nonruptured I Apraxia following nontraumatic I Apraxia following nontraumatic I Apraxia following other nontraumatic intracranial hemorrhage I Apraxia following cerebral infarction I Apraxia following other I Apraxia following unspecified I Ataxia following nontraumatic I Ataxia following nontraumatic I Ataxia following other nontraumatic intracranial hemorrhage I Ataxia following cerebral infarction I Ataxia following other I Ataxia following unspecified I67.1 Cerebral aneurysm, nonruptured Cerebral arteritis I67.7 Cerebral arteritis, not elsewhere classified I68.2 Cerebral arteritis in other s classified elsewhere 2
3 Name Name Cerebral artery occlusion, unspecified, with cerebral infarction I63.50 Cerebral infarction due to unspecified occlusion or stenosis of unspecified I Cerebral infarction due to unspecified occlusion or stenosis of right middle I Cerebral infarction due to unspecified occlusion or stenosis of left middle I Cerebral infarction due to unspecified occlusion or stenosis of unspecified middle I Cerebral infarction due to unspecified occlusion or stenosis of right anterior I Cerebral infarction due to unspecified occlusion or stenosis of left anterior I Cerebral infarction due to unspecified occlusion or stenosis of unspecified anterior I Cerebral infarction due to unspecified occlusion or stenosis of right posterior I Cerebral infarction due to unspecified occlusion or stenosis of left posterior I Cerebral infarction due to unspecified occlusion or stenosis of unspecified posterior I Cerebral infarction due to unspecified occlusion or stenosis of right cerebellar artery I Cerebral infarction due to unspecified occlusion or stenosis of left cerebellar artery I Cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebellar artery I63.59 Cerebral infarction due to unspecified occlusion or stenosis of other I63.8 Other cerebral infarction I63.9 Cerebral infarction, unspecified 3
4 Name Name Cerebral artery occlusion, unspecified, without mention of cerebral infarction I66.01 Occlusion and stenosis of right middle I66.02 Occlusion and stenosis of left middle I66.03 Occlusion and stenosis of bilateral middle cerebral arteries I66.09 Occlusion and stenosis of unspecified middle I66.11 Occlusion and stenosis of right anterior I66.12 Occlusion and stenosis of left anterior I66.13 Occlusion and stenosis of bilateral anterior cerebral arteries I66.19 Occlusion and stenosis of unspecified anterior I66.21 Occlusion and stenosis of right posterior I66.22 Occlusion and stenosis of left posterior I66.23 Occlusion and stenosis of bilateral posterior cerebral arteries I66.29 Occlusion and stenosis of unspecified posterior I66.3 Occlusion and stenosis of cerebellar arteries I66.8 Occlusion and stenosis of other cerebral arteries I66.9 Occlusion and stenosis of unspecified 4
5 Name Name Cerebral embolism, with cerebral infarction I63.40 Cerebral infarction due to embolism of unspecified I Cerebral infarction due to embolism of right middle I Cerebral infarction due to embolism of left middle I Cerebral infarction due to embolism of unspecified middle I Cerebral infarction due to embolism of right anterior I Cerebral infarction due to embolism of left anterior I Cerebral infarction due to embolism of unspecified anterior I Cerebral infarction due to embolism of right posterior I Cerebral infarction due to embolism of left posterior I Cerebral infarction due to embolism of unspecified posterior I Cerebral infarction due to embolism of right cerebellar artery I Cerebral infarction due to embolism of left cerebellar artery I Cerebral infarction due to embolism of unspecified cerebellar artery I63.49 Cerebral infarction due to embolism of other 5
6 Name Name Cerebral embolism, without mention of cerebral infarction I66.01 Occlusion and stenosis of right middle I66.02 Occlusion and stenosis of left middle I66.03 Occlusion and stenosis of bilateral middle cerebral arteries I66.09 Occlusion and stenosis of unspecified middle I66.11 Occlusion and stenosis of right anterior I66.12 Occlusion and stenosis of left anterior I66.13 Occlusion and stenosis of bilateral anterior cerebral arteries I66.19 Occlusion and stenosis of unspecified anterior I66.21 Occlusion and stenosis of right posterior I66.22 Occlusion and stenosis of left posterior I66.23 Occlusion and stenosis of bilateral posterior cerebral arteries I66.29 Occlusion and stenosis of unspecified posterior I66.3 Occlusion and stenosis of cerebellar arteries I66.9 Occlusion and stenosis of unspecified 6
7 Name Name Cerebral thrombosis, with cerebral infarction Cognitive deficits as late effect of Disturbances of vision as late effect of I63.30 Cerebral infarction due to thrombosis of unspecified I Cerebral infarction due to thrombosis of right middle I Cerebral infarction due to thrombosis of left middle I Cerebral infarction due to thrombosis of unspecified middle I Cerebral infarction due to thrombosis of right anterior I Cerebral infarction due to thrombosis of left anterior I Cerebral infarction due to thrombosis of unspecified anterior I Cerebral infarction due to thrombosis of right posterior I Cerebral infarction due to thrombosis of left posterior I Cerebral infarction due to thrombosis of unspecified posterior I Cerebral infarction due to thrombosis of right cerebellar artery I Cerebral infarction due to thrombosis of left cerebellar artery I Cerebral infarction due to thrombosis of unspecified cerebellar artery I63.39 Cerebral infarction due to thrombosis of other I63.6 Cerebral infarction due to cerebral venous thrombosis, nonpyogenic I69.01 Cognitive deficits following nontraumatic I69.11 Cognitive deficits following nontraumatic I69.21 Cognitive deficits following other nontraumatic intracranial hemorrhage I69.31 Cognitive deficits following cerebral infarction I69.81 Cognitive deficits following other I69.91 Cognitive deficits following unspecified I Other sequelae following unspecified 7
8 Name Name Dysphagia as late effect of Dysphasia as late effect of Facial weakness as late effect of I Dysphagia following nontraumatic I Dysphagia following nontraumatic I Dysphagia following other nontraumatic intracranial hemorrhage I Dysphagia following cerebral infarction I Dysphagia following other I Dysphagia following unspecified I Dysphasia following nontraumatic I Dysphasia following nontraumatic I Dysphasia following other nontraumatic intracranial hemorrhage I Dysphasia following cerebral infarction I Dysphasia following other I Dysphasia following unspecified I Facial weakness following nontraumatic I Facial weakness following nontraumatic I Facial weakness following other nontraumatic intracranial hemorrhage I Facial weakness following cerebral infarction I Facial weakness following other I Facial weakness following unspecified 8
9 Name Name Hemiplegia affecting dominant side as late effect of I Hemiplegia and hemiparesis following I Hemiplegia and hemiparesis following I Hemiplegia and hemiparesis following I Hemiplegia and hemiparesis following I Hemiplegia and hemiparesis following I Hemiplegia and hemiparesis following I Hemiplegia and hemiparesis following I Hemiplegia and hemiparesis following I Hemiplegia and hemiparesis following I Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side I Hemiplegia and hemiparesis following cerebral infarction affecting left dominant side I Hemiplegia and hemiparesis following cerebral infarction affecting unspecified side I Hemiplegia and hemiparesis following other affecting right dominant side I Hemiplegia and hemiparesis following other affecting left dominant side I Hemiplegia and hemiparesis following other affecting unspecified side I Hemiplegia and hemiparesis following unspecified I Hemiplegia and hemiparesis following unspecified I Hemiplegia and hemiparesis following unspecified 9
10 Name Name Hemiplegia affecting nondominant side as late effect of I Hemiplegia and hemiparesis following I Hemiplegia and hemiparesis following I Hemiplegia and hemiparesis following I Hemiplegia and hemiparesis following I Hemiplegia and hemiparesis following I Hemiplegia and hemiparesis following I Hemiplegia and hemiparesis following I Hemiplegia and hemiparesis following I Hemiplegia and hemiparesis following other nontraumatic intracranial hemorrhage I Hemiplegia and hemiparesis following cerebral infarction affecting right non-dominant side I Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side I Hemiplegia and hemiparesis following cerebral infarction affecting unspecified side I Hemiplegia and hemiparesis following other affecting right non-dominant side I Hemiplegia and hemiparesis following other affecting left non-dominant side I Hemiplegia and hemiparesis following other affecting unspecified side I Hemiplegia and hemiparesis following unspecified I Hemiplegia and hemiparesis following unspecified I Hemiplegia and hemiparesis following unspecified 10
11 Name Name Hemiplegia affecting unspecified side as late effect of I Hemiplegia and hemiparesis following I Hemiplegia and hemiparesis following I Hemiplegia and hemiparesis following I Hemiplegia and hemiparesis following I Hemiplegia and hemiparesis following I Hemiplegia and hemiparesis following I Hemiplegia and hemiparesis following I Hemiplegia and hemiparesis following I Hemiplegia and hemiparesis following I Hemiplegia and hemiparesis following I Hemiplegia and hemiparesis following I Hemiplegia and hemiparesis following I Hemiplegia and hemiparesis following I Hemiplegia and hemiparesis following I Hemiplegia and hemiparesis following I Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side I Hemiplegia and hemiparesis following cerebral infarction affecting left dominant side 11
12 Name Name Hypertensive encephalopathy I Hemiplegia and hemiparesis following cerebral infarction affecting right non-dominant side I Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side I Hemiplegia and hemiparesis following cerebral infarction affecting unspecified side I Hemiplegia and hemiparesis following other affecting right dominant side I Hemiplegia and hemiparesis following other affecting left dominant side I Hemiplegia and hemiparesis following other affecting right non-dominant side I Hemiplegia and hemiparesis following other affecting left non-dominant side I Hemiplegia and hemiparesis following other affecting unspecified side I Hemiplegia and hemiparesis following unspecified I Hemiplegia and hemiparesis following unspecified I Hemiplegia and hemiparesis following unspecified I Hemiplegia and hemiparesis following unspecified I Hemiplegia and hemiparesis following unspecified I67.4 Hypertensive encephalopathy 12
13 Name Name Intracerebral hemorrhage 431 I61.0 Nontraumatic in hemisphere, subcortical I61.1 Nontraumatic in hemisphere, cortical I61.2 Nontraumatic in hemisphere, unspecified I61.3 Nontraumatic in brain stem I61.4 Nontraumatic in cerebellum I61.5 Nontraumatic, intraventricular I61.6 Nontraumatic, multiple localized I61.8 Other nontraumatic intracerebral hemorrhage I61.9 Nontraumatic, unspecified Moyamoya I67.5 Moyamoya Nonpyogenic thrombosis of intracranial venous sinus Other congenital anomalies of peripheral vascular system Other late effects of Other speech and language deficits as late effect of I67.6 Nonpyogenic thrombosis of intracranial venous system I Other sequelae following nontraumatic I Other sequelae of nontraumatic I Other sequelae of other nontraumatic intracranial hemorrhage I Other sequelae of cerebral infarction I Other sequelae of other I Other sequelae following unspecified I Other speech and language deficits following nontraumatic subarachnoid hemorrhage I Other speech and language deficits following nontraumatic intracerebral hemorrhage I Other speech and language deficits following other nontraumatic intracranial hemorrhage I Other speech and language deficits following cerebral infarction I Other speech and language deficits following other I Other speech and language deficits following unspecified 13
14 Name Name Speech and language deficit, unspecified, as late effect of Subarachnoid hemorrhage I Other speech and language deficits following unspecified 430 I60.00 Nontraumatic from unspecified carotid siphon and bifurcation I60.01 Nontraumatic from right carotid siphon and bifurcation I60.02 Nontraumatic from left carotid siphon and bifurcation I60.10 Nontraumatic from unspecified middle I60.11 Nontraumatic from right middle I60.12 Nontraumatic from left middle I60.20 Nontraumatic from unspecified anterior communicating artery I60.21 Nontraumatic from right anterior communicating artery I60.22 Nontraumatic from left anterior communicating artery I60.30 Nontraumatic from unspecified posterior communicating artery I60.31 Nontraumatic from right posterior communicating artery I60.32 Nontraumatic from left posterior communicating artery I60.4 Nontraumatic from basilar artery I60.50 Nontraumatic from unspecified vertebral artery I60.51 Nontraumatic from right vertebral artery I60.52 Nontraumatic from left vertebral artery I60.6 Nontraumatic from other intracranial arteries I60.7 Nontraumatic from unspecified intracranial artery I60.8 Other nontraumatic subarachnoid hemorrhage I60.9 Nontraumatic, unspecified 14
15 Name Name Unspecified Unspecified late effects of Vertigo as late effect of I67.9 Cerebrovascular, unspecified I69.00 Unspecified sequelae of nontraumatic I69.10 Unspecified sequelae of nontraumatic I69.20 Unspecified sequelae of other nontraumatic intracranial hemorrhage I69.30 Unspecified sequelae of cerebral infarction I69.80 Unspecified sequelae of other I69.90 Unspecified sequelae of unspecified I Other sequelae following unspecified The Provider Specialty Tool Kit is meant to assist providers with documentation best practices necessary for the transition from -CM to -CM. This tool kit includes the most commonly used diagnoses for a specialty using 2012 claims data for top encounters and top number of dollars per diagnosis. The tool kit can be used as a quick reference guide for providers and can also be shared with Practice Managers. This tool kit is not meant to be a coding cross walk and therefore should not be used as such. Questions regarding this tool kit and/or should be submitted via to ICD10@choa.org Children s Healthcare of Atlanta Inc. All rights reserved. SYS ms.3/15 15
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