Mar. 11, 2022 Update: This communication has been edited to include two resource links.
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 4 weeks (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 |
References:
- EncoderPro.com for Payers
- ICD-10-CM Official Guidelines for Coding and Reporting (PDF)
- For questions, please contact the Blue Cross NC Provider Engagement Risk Team
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