Wiki TIA coding

[JAC72]

I need advice on when you code TIA vs. history of TIA. I have a family practice provider who is coding 435.9 - TIA. The documentation says that the patient is there for review of MRI results. He documents in the note that the patient has an appoitment with the neurologist at the end of the month for her recent apparent TIA, and also went on to say that she has no residual effects and no further occurence.

Should this be coded as 435.9 TIA or history of TIA V12.54 since it is not an acute episode?

When does it go from TIA to history of if the provider is still following up with the patient?

Thank you for your help.

 

[jbrightw]

As this is not an acute attack and the patient has no residuals, it can be coded as Hstory, however TIA lasts for about 24 hours only and for that visit only it can be coded as current. The latter visits can be coded as Hx if no residuals and /or late effect if residuals.

Hope that helps

Jesus Brightwin

 

[ValerieBatesHoffCPCCPMA]

V12.54 Personal history of TIA

I agree V12.54 Personal history of TIA would be the appropriate code if the patient recovers from the initial acute episode without any lingering problems related to the stroke.

ICD-9-CM Official Guidelines for Coding and Reporting Effective October 1, 2011 Page 39 of 107

Assign code V12.54, Transient ischemic attack (TIA), and cerebral infarction without residual deficits (and not a code from category 438) as an additional code for history of cerebrovascular disease when no neurologic deficits are present.