Wiki Diagnosis code-help

[graciejean]

A patient seen by neurologist in follow up in the hospital notes:
Rt hemispheric infarct
Repeat CT head Rt (illegible word) infarct with hemorrhagic (illegible word)
will check MRI head tomorrow to determine extent of stroke/hematoma
will hold antithrombolytics for now

434.91 is for the rt hemispheric infarct, would 432.9 be also coded as a second diagnosis for the hemorrhage? or is the hemorrhage included in the 434.91 also?

 

[kmhall]

Stroke w/hemorrage

Yes. I would code both. Note, if the documentation supports it you might look at a late effects code as well. Hope this helps.

 

[graciejean]

Thanks it does help confirm what I thought.