Health Information Management

ICD-9 code for cerebral occlusion, thrombotic with cerebral infarction and hypertensive cardiovascular disease

HIM-HIPAA Insider, May 5, 2009

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Q: What code should I report for a cerebral occlusion, thrombotic with cerebral infarction and hypertensive cardiovascular disease?

A: "Occlusion, brain" in the alphabetic index of the ICD-9 Manual states, "See also infarct, brain." When you search for "infarction, brain, thrombotic," the code is 434.01. For hypertensive cardiovascular disease, search for "hypertensive, cardiovascular disease" in the alphabetical index, which will lead you to code 402.90 (unspecified), code 402.10 (benign), or code 402.00 (malignant). When the physician doesn’t specify whether the hypertensive cardiovascular disease is malignant or benign, it is best practice to query for more information. Most cases will be unspecified; however, when the disease is accelerated, the physician should document malignant. Benign hypertensive cardiovascular disease is rare.

Editor’s note: Sandy Sillman, RHIT, PAHM, DRG coordinator at Henry Ford Health System in Detroit, answered this question that appeared in the April issue of Briefings on Coding Compliance Strategies.



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