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TIA with residual Tremors and weakness

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beckmanj

Contributor
Messages
17
Location
Marana, AZ
PT had a TIA. We are seeing her for a follow up. She has residual tremors and weakness. This was not a CVA. How would you code this?
 
The term 'residual' here is what is confusing. TIA is by definition a 'transient' condition so there would be no residual effects. Does the documentation specially state that the provider feels that these are residual effects of the disease cerebrovascular disease that caused the TIA? If so, then I would use a sequela code. On the other hand, if they mean that these are residual, ongoing symptoms from a prior encounter to evaluate a TIA, but which do not yet have a definitive diagnosis or established cause, then I would code the symptoms with a history of TIA code. But if you can't determine exactly what the provider means by 'residual' from the context of the documentation, a query might be necessary.
 
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