Resolved Stroke w residual

[MaryW_64032]

MCA Stroke and residual hemiparesis. Does this mean it’s a sequela or does it have to say due to in order to code sequela?
Thank you

 

[Darcy]

MCA Stroke and residual hemiparesis. Does this mean it’s a sequela or does it have to say due to in order to code sequela?
Thank you

I do not have enough context to determine if this MCA stroke and residual hemiparesis should be coded as a sequela. However, I can provide some general guidelines on coding sequela after strokes:

- A sequela is the residual effect or condition that is the consequence of a past disease or injury.

- To code a condition as a sequela, the documentation should indicate that the condition is a residual effect or consequence of a previous condition. Phrases like "residual from", "resulting from", or "due to old" help indicate a sequela.

- If the documentation simply states the patient has a current condition, like "MCA stroke and residual hemiparesis", without specifically indicating it is a residual effect of a prior event, it would typically not be considered a sequela.

- The exception is certain conditions like hemiplegia, paraplegia, or monoparesis that are by definition late effects of cerebrovascular disease. These can be assumed to be sequela without explicit documentation indicating so.

So in summary, the documentation would need to explicitly indicate the hemiparesis is specifically residual from or due to the prior MCA stroke for it to be coded as a sequela in this case. Simply stating "MCA stroke and residual hemiparesis" without that link would not be sufficient to code it as a sequela. Let me know if you need any clarification or have additional examples to discuss!