Key points in the documentation of stroke:
– Laterality & Site (identify affected vessel)
– Etiology (occlusion, hemorrhage, thrombosis, stenosis)
– Underlying cause (HTN, Atrial Fibrillation, etc.)
– List any alcohol, drug, tobacco use/abuse/dependence
– List tobacco exposure (second hand, occupational)
Hemiplegia is a comorbidity/complication (CC).
– Document if dominant side for ICD-10
All clinical consequences of a stroke should be listed separately.
– Hemiplegia, as a sequelae of stroke
– Aphasia, as a sequelae of stroke
– Ataxia, as a sequelae of stroke
– Dysphagia, as a sequelae of stroke
Document “history of stroke” only in the PMHx portion.
Download the complete tip, Stroke for ICD-10.