Cardiology Coding Alert

Reader Questions:

Follow Rules for Reporting Intraoperative and Postprocedural CVAs

Published on Mon Jul 26, 2021

Question: I’m trying to learn when I can report an ICD-10-CM code for an intraoperative or postprocedural cerebrovascular accident (CVA). According to the medical documentation, my cardiologist performed an aortic valve replacement on a patient with severe aortic valve stenosis. The patient had a history of atrial fibrillation and has been on anticoagulation therapy, which was discontinued according to guidelines. During the procedure, my cardiologist documented there was a sudden drop in the patient’s blood pressure and hemodynamic instability. My cardiologist discontinued the procedure, which he states in the report was due to an intraoperative cerebral vascular infarction. Which ICD-10-CM code should I report?

Alaska Subscriber

Answer: You should report I97.810 (Intraoperative cerebrovascular infarction during cardiac surgery) on your claim.

Don’t miss: The ICD-10-CM Official Guidelines for Coding and Reporting offer some very specific rules for how to report intraoperative and postprocedural CVAs.

First, your cardiologist’s medical documentation must clearly identify the cause-and-effect relationship between the medical intervention and the CVA.

Second, you should choose the appropriate ICD-10-CM code based upon whether the accident was an infarction or hemorrhage. If it is a cerebral hemorrhage, the code assignment will depend upon the procedure performed.

Lastly, you must determine if the CVA occurred intraoperatively or postoperatively.