Is using the I63 for primary and I69 for follow-up care appropriate after the patient leaves the hospital? What impact would this have on the payment? Where can I go to learn more?
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Resolved ICD-10-CM for Stroke Outpatient Coding
- Thread starter YvonneE_73326
- Start date
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- Tags
- #stroke
Lori
Well-known member
Coding acute stroke accurately requires the documentation to note the following:
1. 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.
2. 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.
3. Unconfirmed Stoke Diagnoses in outpatient setting: Do not code diagnoses documented as
probably, 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.
4. 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.
5. 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).
6. Transient ischemic attack (TIA)
a. When a TIA is diagnosed, a separate code is used (G45.9). This can be referred to as a “mini
stroke” but should be considered separate from coding for a cerebral infarct.
ICD-10 Categories I60-I69 Cerebrovascular Disease:
The ICD-10 Table of Diseases organizes cerebrovascular disease codes as follows:
I60-162* Non-traumatic intracranial hemorrhage
I63* Cerebral Infarctions
I65-I66* Occlusion and stenosis of cerebral of 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.
1) Precerebral arteries include:
a) Vertebral artery
b) Basilar Artery
c) Carotid Artery
2) Cerebral arteries include:
a) Anterior cerebral artery
b) Middle cerebral artery
c) Posterior cerebral artery
Cerebral infarction
Use Additional
code, if applicable, to identify status post administration of tPA (rtPA) in a different facility within the last 24 hours prior to admission to current facility (Z92.82)
Type 1 Excludes
neonatal cerebral infarction (P91.82-)
Type 2 Excludes
sequelae of cerebral infarction (I69.3-)
Includes
occlusion and stenosis of cerebral and precerebral arteries, resulting in cerebral infarction
Code category I67-I68* specifies other cerebrovascular diseases and cerebrovascular disorders in diseases classified elsewhere.
ICD-10 code category I69* does NOT require two codes. Codes in this category describe the type of stroke and the sequelae (late effect) caused by the stroke. Documentation in the medical record should clearly state whether a neurological deficit is directly related to cerebrovascular disease or a cerebrovascular accident.
Codes from category I69* will only be used in conjunction with codes from categories I60-I68* (Cerebrovascular diseases) if a patient has a current cerebrovascular disease and also has sequelae (late effects) from an old cerebrovascular disease.
A code from category I69* can be reported in conjunction with a condition classifiable to code category I60-I67* if the patient has a current cerebrovascular disease and sequelae (late effects) from an old cerebrovascular disease.
If a physician clearly documents that a patient is being seen who has a history of cerebrovascular disease or accident with residual effects, a code from category I69* should be assigned.
If the affected side is documented, but not specified as dominant or non-dominant, and the classification system does not have a default, code selection is as follows:
1. If the right side is affected, the default is dominant
2. If the left side is affected, the default is non-dominant.
3. For ambidextrous patients, the default should be dominant.
When coding sequelae of cerebrovascular disease (late effects), the documentation should ALWAYS clearly state what the sequelae or residual effect is. If the documentation does not specify what the sequelae is, an unspecified code can be selected.
If a physician clearly documents bilateral non-traumatic subarachnoid hemorrhage sites, an ICD-10 code must be assigned for each site if no bilateral ICD-10 code exists
Note
Category I69 is to be used to indicate conditions in I60-I67 as the cause of sequelae. The 'sequelae' include conditions specified as such or as residuals which may occur at any time after the onset of the causal condition
Type 1 Excludes
personal history of cerebral infarction without residual deficit (Z86.73)
personal history of prolonged reversible ischemic neurologic deficit (PRIND) (Z86.73)
personal history of reversible ischemic neurologcial deficit (RIND) (Z86.73)
sequelae of traumatic intracranial injury (S06.-)
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.
Coding guidelines state that the late effects (sequelae) caused by a stroke may be present from the onset of a stroke or arise at
ANY time after the onset of the stroke.
If a patient is NOT EXPERIENCING A CURRENT CEREBROVASCULAR ACCIDENT (CVA) and has no residual or late effect
from a previous CVA, Z86.73
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.
Alicia did this video on aftercare & Z codes:
FOLLOW-UP • Implies the disease, condition, or injury has been fully treated and no longer exists. • Used to explain continuing surveillance following completed treatment of a disease, condition, or injury. • Should not be confused with aftercare codes that explain current treatment for a healing condition or its sequelae. • May be used in conjunction with history codes to provide the full picture of the healed condition and its treatment. • When used together, the follow-up code is sequenced first, followed by the history code.
AFTERCARE • Initial treatment of a disease or injury has been performed. • Patient requires continued care during the healing or recovery phase, or for the long term consequences of the disease; typically this is the global period. • Aftercare for injuries, during the healing and recovery phase, should be coded with the injury code and the appropriate 7th character for subsequent encounter rather than a Z code. • NOT reported if treatment is currently being directed at an acute disease or acute injury
Consider Treatment, Recovery When Choosing Between Code Sets
If you’re working on a patient’s postoperative visit and are unsure of whether the visit justifies the use of an aftercare code or a follow-up code, you’ll want to have a look at the ICD-10-CM guidelines to compare and contrast both options. One of your primary considerations surrounding the patient’s postoperative visit should be determining whether treatment is ongoing or if the patient is in the recovery phase. Have a look at the following aftercare coding guideline:
1. 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.
2. 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.
3. Unconfirmed Stoke Diagnoses in outpatient setting: Do not code diagnoses documented as
probably, 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.
4. 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.
5. 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).
6. Transient ischemic attack (TIA)
a. When a TIA is diagnosed, a separate code is used (G45.9). This can be referred to as a “mini
stroke” but should be considered separate from coding for a cerebral infarct.
ICD-10 Categories I60-I69 Cerebrovascular Disease:
The ICD-10 Table of Diseases organizes cerebrovascular disease codes as follows:
I60-162* Non-traumatic intracranial hemorrhage
I63* Cerebral Infarctions
I65-I66* Occlusion and stenosis of cerebral of 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.
1) Precerebral arteries include:
a) Vertebral artery
b) Basilar Artery
c) Carotid Artery
2) Cerebral arteries include:
a) Anterior cerebral artery
b) Middle cerebral artery
c) Posterior cerebral artery
Cerebral infarction
Use Additional
code, if applicable, to identify status post administration of tPA (rtPA) in a different facility within the last 24 hours prior to admission to current facility (Z92.82)
Type 1 Excludes
neonatal cerebral infarction (P91.82-)
Type 2 Excludes
sequelae of cerebral infarction (I69.3-)
Includes
occlusion and stenosis of cerebral and precerebral arteries, resulting in cerebral infarction
Code category I67-I68* specifies other cerebrovascular diseases and cerebrovascular disorders in diseases classified elsewhere.
ICD-10 code category I69* does NOT require two codes. Codes in this category describe the type of stroke and the sequelae (late effect) caused by the stroke. Documentation in the medical record should clearly state whether a neurological deficit is directly related to cerebrovascular disease or a cerebrovascular accident.
Codes from category I69* will only be used in conjunction with codes from categories I60-I68* (Cerebrovascular diseases) if a patient has a current cerebrovascular disease and also has sequelae (late effects) from an old cerebrovascular disease.
A code from category I69* can be reported in conjunction with a condition classifiable to code category I60-I67* if the patient has a current cerebrovascular disease and sequelae (late effects) from an old cerebrovascular disease.
If a physician clearly documents that a patient is being seen who has a history of cerebrovascular disease or accident with residual effects, a code from category I69* should be assigned.
If the affected side is documented, but not specified as dominant or non-dominant, and the classification system does not have a default, code selection is as follows:
1. If the right side is affected, the default is dominant
2. If the left side is affected, the default is non-dominant.
3. For ambidextrous patients, the default should be dominant.
When coding sequelae of cerebrovascular disease (late effects), the documentation should ALWAYS clearly state what the sequelae or residual effect is. If the documentation does not specify what the sequelae is, an unspecified code can be selected.
If a physician clearly documents bilateral non-traumatic subarachnoid hemorrhage sites, an ICD-10 code must be assigned for each site if no bilateral ICD-10 code exists
Note
Category I69 is to be used to indicate conditions in I60-I67 as the cause of sequelae. The 'sequelae' include conditions specified as such or as residuals which may occur at any time after the onset of the causal condition
Type 1 Excludes
personal history of cerebral infarction without residual deficit (Z86.73)
personal history of prolonged reversible ischemic neurologic deficit (PRIND) (Z86.73)
personal history of reversible ischemic neurologcial deficit (RIND) (Z86.73)
sequelae of traumatic intracranial injury (S06.-)
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.
Coding guidelines state that the late effects (sequelae) caused by a stroke may be present from the onset of a stroke or arise at
ANY time after the onset of the stroke.
If a patient is NOT EXPERIENCING A CURRENT CEREBROVASCULAR ACCIDENT (CVA) and has no residual or late effect
from a previous CVA, Z86.73
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.
Alicia did this video on aftercare & Z codes:
FOLLOW-UP • Implies the disease, condition, or injury has been fully treated and no longer exists. • Used to explain continuing surveillance following completed treatment of a disease, condition, or injury. • Should not be confused with aftercare codes that explain current treatment for a healing condition or its sequelae. • May be used in conjunction with history codes to provide the full picture of the healed condition and its treatment. • When used together, the follow-up code is sequenced first, followed by the history code.
AFTERCARE • Initial treatment of a disease or injury has been performed. • Patient requires continued care during the healing or recovery phase, or for the long term consequences of the disease; typically this is the global period. • Aftercare for injuries, during the healing and recovery phase, should be coded with the injury code and the appropriate 7th character for subsequent encounter rather than a Z code. • NOT reported if treatment is currently being directed at an acute disease or acute injury
- The aftercare Z code should not be used if treatment is directed at a current, acute disease.
- The aftercare Z codes should also not be used for aftercare for injuries.
- Certain aftercare Z code categories need a secondary diagnosis code to describe the resolving condition or sequelae. For others, the condition is included in the code title.
- Additional Z code aftercare category terms include fitting and adjustment, and attention to artificial openings.
Consider Treatment, Recovery When Choosing Between Code Sets
If you’re working on a patient’s postoperative visit and are unsure of whether the visit justifies the use of an aftercare code or a follow-up code, you’ll want to have a look at the ICD-10-CM guidelines to compare and contrast both options. One of your primary considerations surrounding the patient’s postoperative visit should be determining whether treatment is ongoing or if the patient is in the recovery phase. Have a look at the following aftercare coding guideline:
- “Aftercare visit codes cover situations when the initial treatment of a disease has been performed and the patient requires continued care during the healing or recovery phase, or for the long-term consequences of the disease. The aftercare Z code should not be used if treatment is directed at a current, acute disease. The diagnosis code is to be used in these cases.”
- “The follow-up codes are used to explain continuing »surveillance following completed treatment of a disease, condition, or injury. They imply that the condition has been fully treated and no longer exists.”
I appreciate the excellent and in-depth explanation. I'm auditing DME billed with I63. Where would I look to determine the financial impact of the incorrect use of the I63 as primary in DME billing? Thank you for your guidance, as I am new to auditing and coding.
Lori
Well-known member
Audit Findings
OIG found nearly all of the selected acute stroke diagnosis codes that physicians submitted to CMS under traditional Medicare — that CMS later used to make payments to MA organizations in 2015-2016 on behalf of the 582 transferred enrollees — did not comply with federal requirements.Only two of the 582 cases that had acute stroke diagnoses were supported by the documentation. Conversely, the medical records in 99.7 percent of patients lacked evidence of an acute stroke. Thus, the Ischemic/Unspecified Stroke HCCs were not validated. Because these specific diagnosis codes map to the HCCs for Ischemic or Unspecified Stroke, CMS was at risk of having made inaccurate payments.
The errors occurred due to physicians submitting incorrect acute stroke diagnosis codes on claims billed under traditional Medicare. The miscoding went unnoticed during the patient’s transfer to MA and subsequently caused erroneous overpayments. The OIG states that this happened because CMS did not have policies to identify beneficiaries who transferred or procedures to evaluate whether the acute stroke diagnosis codes reported on their behalf complied with federal requirements.
ICD-10-CM diagnosis codes identified as at high risk for noncompliance with coding guidelines include:
I63.30 Cerebral infarction due to thrombosis of unspecified cerebral artery
I63.40 Cerebral infarction due to embolism of unspecified cerebral artery
I63.50 Cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery
In most cases, a diagnosis of history of stroke — which does not map to an HCC — should have been reported. Incorrect reporting of these codes for acute stroke made under traditional Medicare resulted in inaccurate payments of just over $14.4 million on behalf of the individuals transferred to MA the following year.
Miscoded Acute Stroke Diagnoses Cost Millions
More than $14.4 million in inaccurate payments were made to MA organizations due to submission of incorrect acute stroke diagnosis codes, OIG finds.
Thank you! You are amazing! I appreciate your help with understanding stroke coding.