Physicians/Specialists
Facilities/Hospitals
Publication Date: 
2021-08-11

August 11, 2021 Update: This communication has been reposted for further awareness to providers. This update was originally posted on August 4, 2021. 


As a resource for providers, coders and practice managers, Blue Cross and Blue Shield of North Carolina (Blue Cross NC) has created a brief education document to describe the proper coding for Acute Myocardial Infarction (MI) and ​Cerebral Infarction (CVA). The guide below aims to assist with accurate, complete documentation & coding that reflects the true nature of a patient’s current health status at the highest level of specificity. 

Per ICD-10 official guidelines for reporting and coding “Personal history codes explain a patient’s past medical condition that no longer exists and is not receiving any treatment, but that has the potential for recurrence, and therefore may require continued monitoring. A history of an illness, even if no longer present, is important information that may alter the type of treatment ordered.” ​

 

Acute Myocardial Infarction vs. History of MI​

ICD-10​

Description​

Coding Guidance​

Example of when to use of codes in this category ​

I21.x​

STEMI and NSTEMI (Acute)​

MI specified as acute or with a stated duration of 4weeks (28 days) or less from onset​

Member hospitalized on 5/2/21 for Acute non-ST MI. Seen by PCP for a follow-up visit on 5/20/21.  ​

I22.x ​

Subsequent MI​

Acute MI occurring within 4 weeks (28 days) of a previous acute MI​

Member experienced a subsequent non-ST elevation MI less than 3 weeks after the onset of the previous event.​

I25.2​

Old MI​

Healed or past MI diagnosed by ECG or other investigation, currently presenting no symptoms.​

Member had MI in 2007​

 

Cerebral Infarction (CVA) vs. Transient Ischemic Attack (TIA) vs. History of TIA or CVA​

ICD-10​

Description​

Coding Guidance​

Example of when to use of codes in this category​

I63.x ​

Acute cerebral infarction (CVA)​

Acute, current cerebrovascular infarction​

Member transported via EMS to ED, admitted to hospital for stroke.​

G45.9​

Transient ischemic attack (TIA)​

Member seen in ER for complaints of left sided weakness which occurred earlier that morning but has since resolved. After evaluation in ER was diagnosed as having had a TIA.​

I69.x ​

Sequelae of Cerebrovascular Disease​

Code the neurologic deficits that persist after initial onset of CVA (i.e., hemiplegia/paresis,monoplegia/paresis, dysphagia, etc.)​

Member seen for follow-up visit, had CVA in 2016, which resulted in persistent right dominant side hemiparesis.​

Z86.73​

History of TIA or CVA , no residual deficits​

Member seen for AWV. Previous CVA in 2017, doing well and doesn’t have late effects or residual, persisting deficits​

 

For questions, please contact the Blue Cross NC Provider Engagement Risk Team.