Radiology Coding Alert

Some coders don’t take into account anything more than what’s offered in the dictation report when it comes to coding strokes. However, in order to reach the correct degree of specificity, a coder needs to understand each different dynamic at play when the physician documents a cerebral infarction in the findings or impression.

There are no universal guidelines that determine when a stroke goes from acute to chronic. Generally speaking, a disease can be considered chronic if its symptoms extend beyond three months, according to the U.S. National Center for Health Statistics (NCHS). However, in the realm of cerebral infarctions, this timetable is not necessarily correct. Barry Rosenberg details the steps in which an acute stroke becomes chronic:

• Prior to 24 hours: hyperacute stroke
• 24 hours to seven days: acute stroke
• Seven days to one month: subacute stroke
• Greater than one month: chronic stroke

Where this question becomes tricky is when you’re asked to supply a diagnosis code to these specific post-infarction states. Take a look at a few examples to determine which cerebral infarction codes are applicable in particular circumstances.

Example 1: The indication states “stroke” and the impression documents an MCA infarct.

Here, we’re left without any sort of timetable. Since the report does not document the cause of the infarction, opt for code I63.9 (Cerebral infarction, unspecified).

Example 2: The indication states “stroke two weeks ago” in addition to symptoms of dizziness, loss of balance, and visual impairment. The impression reveals an infarction of the right anterior cerebral artery.

Since the symptoms have persisted, the patient is in the subacute period of a cerebral infarction. Code for all hyperacute, acute, and subacute strokes under the I63.- category of ICD-10 codes. In this case, you would again code as I63.9 since there is no additional information besides the location of the infarction.

Disclaimer: If you’re working on a report with an indication of a stroke, yet the physician does not document a stroke in the findings or impression, you will want to send the report back for review. If follow-up imaging is performed on a stroke that was previously found on an MRI, there will be evidence of the prior stroke on the follow-up scan as well. If a patient presents for an initial brain scan with an indicating diagnosis of a stroke, you will also want to send the report back.

A stroke can only be definitively diagnosed through imaging. So, a patient, by definition, can only present with stroke symptoms until the imaging is performed. If a patient has stroke symptoms which immediately dissipate and the brain scan does not document a cerebral infarction, the physician can include the diagnosis of a transient ischemic attack (TIA).

What if? If the indication only offered a timeframe of two weeks without reference to symptoms, you will still code I63.9. However, this is only true if the physician documents a current (acute or chronic) cerebral infarction on the scan. If the report documents an old cerebral infarction, apply code Z86.73 (Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits).

Example 3: The indication states “stroke six months ago” in addition to various symptoms such as dysphasia, memory impairment, and aphasia. You will code this the same regardless of whether or not an old or acute stroke is documented on the brain scan. If stroke symptoms exist more than one month after its occurrence, you should consider the stroke chronic. In the case of ICD-10 coding, you should consider a chronic stroke and sequelae of cerebral infarction to be one in the same. For this example, you will apply the following three codes:

• I69.321 (Dysphasia following cerebral infarction)
• I69.311 (Memory deficit following cerebral infarction)
• I69.320 (Aphasia following cerebral infarction)

Caution: Occasionally, you might come across an indicating diagnosis resembling something along the lines of “stroke alert.” You should be aware that this term is not equivalent to that of a stroke.

“Providers should not use the term ‘stroke alert’ to indicate why a patient may need a brain MRI or CT scan,” according to Lindsay Della Vella. “From a coding standpoint, this is not enough to warrant the use of a stroke diagnosis. In these instances, providers should document whatever symptoms accompany the stroke alert diagnosis (slurred speech, visual impairment, numbness, etc.). If only ‘stroke alert’ is documented, the report should be sent back for an addendum. Coders want to be 100 percent sure that the patient had a stroke before coding it on their record.”

Remember: Only code these reports using a cerebral infarction diagnosis code if a cerebral infarction is found during the brain scan.