Wiki Z79.02

[nehaaggarwal]

Dear Team,

I need your advise on the below query.

Patient has come for hematuria and has history of stroke. He has been using plavix for his stroke history but for today's visit, doctor has told the patient to stop using Plavix.

Should we code for stroke history? if Yes should we code this with Z79.02.


Thank you
Best Regards,
Neha

 

[blazingburgundy1]

History of stroke and of long term use of prescribed antiplatelet drug

Hello Neha,

If the provider has just informed the patient during this new encounter to discontinue the use of Plavix, for the purpose of the current encounter's coding assignment, the patient has been taking the Plavix and through that encounter date has had a personal history of taking antiplatelet drug. Please see the FY 2018 ICD-10-CM Official Guidelines for Coding and Reporting, Section I.C.21.c.(3) "Status" note at Z79 - (page 90 of 117) and Section I.C.21.c.(4) "History (of)" note at Z86 - (page 92 of 117). https://www.cms.gov/Medicare/Coding/ICD10/Downloads/2018-ICD-10-CM-Coding-Guidelines.pdf

Both of these should be assigned (but not as the primary Dx):

Z86.73 Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits
Z79.02 Long term (current) use of antithrombotics/antiplatelets

Sincerely,

Liz Wilson