EM Coding Alert
Confidently Code a Stroke From Encounter Through Dx
Also, remember to choose the correct ICD-10-CM code for each patient. There are many options for diagnosis and treatment that providers may pursue when seeing a patient presenting with signs or symptoms of a stroke. One of the key elements in successfully and accurately coding such an encounter is identifying the appropriate evaluation and management (E/M) service. Correctly reporting any imaging coding options and diagnoses is critical to accuracy of the patient’s medical record and reimbursement, too. Understand How a Stroke May Appear A cerebrovascular accident (CVA), also known as a stroke or cerebral infarction, occurs when the patient experiences a disruption in the blood flow to the brain. When the blood flow is interrupted, the brain cells don’t receive the nutrients and oxygen needed from blood and begin to die within a short amount of time. Common signs that a patient has experienced a stroke include: Notice Locale to Select E/M A stroke patient, like all undiagnosed patients, will undergo an E/M service, so the surgeon can assess the patient prior to any further testing. This could occur in the office, in which case you’d choose a code from 99202 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/ or examination and straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is spent on the date of the encounter.) through 99215 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using time for code selection, 40-54 minutes of total time is spent on the date of the encounter.). Due to the severity of the condition — and the fact that your surgeon might not have all the testing equipment needed in the office — they might meet the patient at a local facility instead. When this occurs, coding for the E/M changes. You’ll choose a hospital E/M for the service (inpatient, observation, consultation, emergency department (ED), etc.). Find Evidence of Any Imaging Test When the patient presents to the surgeon to receive care for a possible stroke, healthcare professionals have several imaging modalities at their disposal to detect and diagnose the condition. The imaging options available for diagnosing a CVA include, but are not limited to: Each imaging modality has its own benefits. For example, NCCT scans are ideal for imaging immediately after the provider has stabilized the patient. NCCT is used to help exclude hemorrhagic stroke and can identify calcification, which makes it possible to detect lesions. A provider may perform a duplex ultrasound to screen for carotid artery stenosis if the patient is suspected to have experienced a stroke. Rely on Modifier 26 for Facility-Based Tests If your surgeon does meet a patient at the hospital when they experience stroke symptoms and performs the interpretation of the diagnostic imaging studies, be sure to append modifier 26 (Professional component) to any imaging test performed. Remember, you need to append modifier 26 if the surgeon uses imaging equipment that isn’t owned by your practice. Don’t Forget About ICD-10-CM If you receive a report that states the provider diagnosed the patient with a stroke or CVA, the ICD-10-CM code set has several code options available in the I63.- (Cerebral infarction) code category. The following code subcategories allow you to assign an appropriate code for a CVA diagnosis where the physician identifies the cause of the stroke: Except for I63.6, each code subcategory listed above can be further expanded to a 5th and sometimes 6th character to complete the codes. You’ll use a 6th character in the I63.0- to I63.5- code subcategories to specify the circulatory structure affected and laterality. If the provider documents a stroke or CVA without any additional information, you’ll assign the default code of I63.9 (Cerebral infarction, unspecified). This code features an additional synonym of “Stroke NOS,” which stands for not otherwise specified and lines up with the provider’s diagnosis. Look Closely at Parent Code Notes The I63.- code category features two notes instructing you to use additional codes if certain criteria are met. One note directs you to use Z92.82 (Status post administration of tPA (rtPA) in a different facility within the last 24 hours prior to admission to current facility) to identify that the patient was administered tissue plasminogen activator (tPA) or recombinant tissue plasminogen activator (rtPA) at a different facility before being admitted to the current facility. “tPA is used quickly after stroke onset to help restore blood flow to brain regions by dissolving blood clots blocking blood flow. rtPA has been considered the standard of care for treatment of acute ischemic stroke,” says Kristen Taylor, CPC, CHC, CHIAP, associate partner of Pinnacle Enterprise Risk Consulting Services in Centennial, Colorado. According to Z92.82’s descriptor, the tPA or rtPA administration must have occurred within the previous 24 hours in a different facility for you to accurately report the code. The other “use additional code” note instructs you to assign the appropriate National Institutes of Health Stroke Scale (NIHSS) score from the R29.7- (National Institutes of Health Stroke Scale (NIHSS) score) subcategory. Report Late-Term Effects in These Situations Patients who have experienced a stroke or CVA may also experience late-term effects, or sequela, after the initial incident. “Sequelae are residual effects or conditions produced after the acute phase of an illness or injury has ended,” says Grabiela Juarez, COC, CPC, CPMA, Approved Instructor, revenue cycle specialist of Sceptre Management and owner of Medical Coding Vida Academy in Salt Lake City. Residual effects may be apparent soon after the illness or injury, or the sequela may occur months or years later. “Therefore, there is no time limit on when a sequela code can be assigned,” Juarez adds. You’ll use the I69- (Sequelae of cerebrovascular disease) category to report any sequelae related to a cerebral infarction, CVA, or stroke.
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