Health Information Management

Coding Clinics highlight documentation’s critical role in accurate stroke coding

JustCoding News: Inpatient, December 7, 2011

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Clinical documentation plays a vital role in all coding. It is especially important, however, when reporting conditions such as stroke, which more often than not involves multiple symptoms, diagnoses, and complications.

Through the years, The American Hospital Association’s (AHA) Coding Clinic on ICD-9-CM has tackled a variety of stroke-related questions, both common and complicated. Taking a closer look at that guidance helps to remind those responsible for documentation and coding that accurate coding hinges upon the details.

Hemiplegia as an additional diagnosis

AHA’s Coding Clinic, First Quarter, 2010, addressed a question regarding a patient who had a stroke and documented hemiplegia. Guidance discussed whether to report the hemiplegia as an additional diagnosis for this patient due to the stroke.

In contrast to previously published guidance, this Coding Clinic stated that because hemiplegia is not inherent in an acute cerebrovascular accident, coders should report the hemiplegia. This is true even if the condition has resolved with or without treatment at the time of hospital discharge.

“This current advice supersedes previous Coding Clinic advice, so it’s really important to make sure that you share that with all of your [clinical documentation improvement (CDI)] staff and certainly [health information management (HIM) and] coding staff,” said Gloryanne Bryant, BS, RHIA, RHIT, CCS, CCDS, regional managing director HIM, NCAL Revenue Cycle, at Kaiser Foundation Health Plan, Inc. & Hospitals in Oakland, CA. Bryant spoke during HCPro’s October 28 audio conference, “Coding Clinic for ICD-9-CM and Documentation Improvement Opportunities: Best Practices for CDI and Coding Compliance.”

James S. Kennedy, MD, CCS, managing director at FTI Consulting in Brentwood, TN, further emphasized the significance of this change. “The fact that we can now report any neurological deficit caused by a stroke even if it’s resolved at the time of discharge is absolutely huge,” said Kennedy, who explained that many times patients present with a symptom, such as weakness, seizures, or aphasia. However, if these symptoms resolved during the stay, many physicians did not even bother to summarize them at the time of discharge.

Symptom versus diagnosis

Consider the documentation of a symptom versus a diagnosis. The term weakness is a symptom, whereas monoparesis, hemiparesis, or quadriparesis is a diagnosis, said Kennedy, who emphasized the importance of encouraging physicians to be specific in their documentation of a diagnosis over a symptom when appropriate. For example, a seizure in ICD-9-CM is a symptom code, whereas a seizure disorder is a diagnosis.

Also, consider the following common neurological consequences of a stroke and determine whether to remind your physicians to document these more explicitly when appropriate:

  • Broca’s aphasia: Speech is halting, stuttering, labored, and difficult to initiate
  • Wernicke’s aphasia: Grammar, syntax, rate, intonation, and stress in speech is normal, but the language content is incorrect
  • Speech apraxia: Person has trouble saying what he or she wants to say correctly and consistently
  • Anomia: Inability to name objects

According to the ICD-9-CM Official Guidelines for Coding and Reporting, providers must differentiate whether these symptoms are current or related to the current stroke, or whether they’re a late effect of a previous stroke, Kennedy said.

Also, consider acute altered mental states or levels of consciousness as a result of a stroke:

  • Stupor (code 780.09): Deep sleep or similar unresponsiveness
  • Coma (code 780.01): State of unresponsiveness in which the patient lies with eyes closed and cannot be aroused, even with vigorous stimulation
  • Locked-in syndrome (code 344.81): A fully conscious individual with paralysis of all four limbs and lower cranial nerves

When physicians describe patients as “unresponsive,” query for the level of unresponsiveness (e.g., stupor versus coma) because it can affect the risk adjustment in MS-DRGs and APR-DRGs, Kennedy said.

Cerebral edema due to stroke

Coding Clinic, First Quarter, 2010, p. 8 addressed a question related to cerebral edema due to stroke. “Cerebral edema is very tricky because as an MCC and as a relatively high-weighted condition in APR-DRGs and MS-DRGs, there should be some clinical evidence that it’s significant,” Kennedy said.

The Coding Clinic responded to a question regarding whether it is appropriate to code vasogenic edema when the physician documents it for a patient admitted and diagnosed with intracerebral hemorrhage. The response indicated that it is appropriate to assign code 431 (intracerebral hemorrhage) as the principal diagnosis and code 348.5 (cerebral edema) as an additional diagnosis. But coders should be able to defend this with documentation of clinical circumstances, such as if the patient is:

  • In the intensive care unit
  • Intubated
  • Receiving glycerol, diuretics, or high-dose steroids
  • Possibly undergoing surgery

“This would then support that this was a clinically significant cerebral edema that altered the length of stay, resource utilization, and would quality as an additional diagnosis,” Kennedy said.

Hemorrhagic conversion of stroke

Coding Clinic, First Quarter, 2010, p. 5 addressed hemorrhagic conversion of stroke. A physician admitted a 77 year old with expressive aphasia and documented that it was due to an acute cerebral infarction. The physician ordered and documented IV tissue plasminogen activator (tPA) within 4.5 hours of onset of symptoms, as approved by the Food and Drug Administration. After the tPA, there was evidence of an asymptomatic hemorrhagic conversion of the stroke caused by the tPA, despite the fact that the physician administered the tPA as directed (i.e., it was not an accidental overdose). Coding Clinic stated the following codes are appropriate to report for this scenario:

  • 434.91 (cerebral artery occlusion, unspecified, with cerebral infarction) as the principal diagnosis
  • 997.02 (iatrogenic cerebrovascular infarction or hemorrhage)
  • 431 (intracerebral hemorrhage) for the cerebral hemorrhagic conversion due to the thrombolytic therapy
  • 784.3 (aphasia)
  • E934.4. (drugs, medicinal, and biological substances causing adverse effects in therapeutic use, fibrinolysis-affecting drugs) as additional diagnosis

Coding Clinic emphasized the use of code 997.02, which is a complication code,” Kennedy said. “I found that to be interesting because as a coder, I did not equate the therapeutic use of any drug that has an adverse effect to be reported with a complication code.”

According to ICD-9-CM Official Guidelines for Coding and Reporting for adverse effects, when drugs are correctly prescribed and properly administered, coders are supposed to code the reaction as well as the appropriate code from the E930–E949 series.

Yet, the index indicates that if the cerebral hemorrhage or infarction occurs as a result of a medical intervention, documentation should clearly identify the cause and effect between the medical intervention and the cerebrovascular accident, and coders should assign code 997.02.

“In essence, Coding Clinic applied this guideline and determined that the administration of tPA was a medical intervention,” Kennedy said.

Consider other clinical circumstances in which there are other drugs that can be a direct cause of stroke or could be construed as medical interventions (e.g., heparin or warfarin can lead to a cerebral hemorrhage). How to code these other scenarios that could possibly be considered interventions is uncertain, and may warrant clarification from Coding Clinic, Kennedy said.

Make sure the documentation clearly specifies a cause-and-effect relationship, Bryant said. “That’s really the key here,” she said. “Certainly if you cannot identify that [relationship] in the documentation, it’s inappropriate for CDI and or HIM/coding to query.”

This is especially important if the cerebral hemorrhage led to an intracranial vascular procedure, Kennedy added. MS-DRGs 20–22 (Intracranial vascular procedure with a principal diagnosis of hemorrhage) are higher weighted than MS-DRGs for intracranial vascular procedures, whereby the MDC 1 principal diagnosis is not a cerebral hemorrhage. Note that code 997.02 (iatrogenic cerebrovascular infarction of hemorrhage) as a principal diagnosis does not qualify for the higher weighted MS-DRG 20–22. “For this reason,” Kennedy said, “capturing and sequencing code 997.02 correctly is critical in accurate ICD-9-CM code and MS-DRG assignment.”

Note that if the hemorrhage is spontaneous and unrelated to a medical intervention, you should not assign code 997.02. For example, Coding Clinic, Third Quarter, 2010, pp. 5–6 addressed a scenario in which a patient sustained a left frontal cerebral infarction with hemorrhagic conversion. The provider documented that the patient presented with expressive aphasia due to an acute cerebral infarct and later developed hemorrhagic conversion of the infarct. When queried, the provider stated that this hemorrhagic conversion was spontaneous.

For this scenario, assign code 434.91 (cerebral artery occlusion, unspecified, with cerebral infarction) and code 431 (intracerebral hemorrhage), according to Coding Clinic.

“We really need to know what’s the underlying cause of the conversion,” Bryant said. “It’s going to be very important that you have that cause-and-effect relationship clearly stated.”

Severity of illness and risk of mortality

Examining the CC or MCC status of some of the conditions we’ve discussed in this article and taking into account the effect on the APR-DRG serves to emphasize the importance of encouraging physicians to provide complete documentation so that the appropriate severity of illness and risk of mortality is captured, Kennedy said.

“One of the problems that we run into is that physicians will typically document a cause of death as it relates to stroke or heart attack, but they do not discuss the mechanism of death or decline,” Kennedy explained. “This is an area where coding professionals, concurrent reviewers, and providers should be very clear to describe the mechanism of death in stroke, such as cerebral edema, brain death, acute respiratory failure, and the like, which is what differentiates why the patient died during the inpatient admission versus being discharged.”

Bryant agreed. “Showing severity of illness and risk of mortality is really important to your outcomes and quality, and it’s going to be a real driving factor in the future,” she said.

Editor’s note: E-mail questions to Managing Editor Doreen V. Bentley at To learn more about Coding Clinic guidance regarding pulmonary conditions, renal conditions, or postoperative hemorrhage and postoperative hematoma, purchase a copy of HCPro’s October 28 audio conference “Coding Clinic for ICD-9-CM and Documentation Improvement Opportunities: Best Practices for CDI and Coding Compliance.”

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