ICD-10 Coding for History of Cerebral Infarction(I69.351, Z86.73)
Complete ICD-10-CM coding and documentation guide for History of Cerebral Infarction. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to History of Cerebral Infarction
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| I69.351 | Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side | Use when there is documented right-sided weakness linked to a past cerebral infarction. |
|
| Z86.73 | Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits | Use when the patient has a history of stroke but no current residual deficits. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for history of cerebral infarction
Essential facts and insights about History of Cerebral Infarction
Primary ICD-10-CM Codes for history of cerebral infarction
Decision Criteria
clinical Criteria
- Presence of right-sided weakness linked to past stroke
Applicable To
- Right-sided hemiparesis due to past stroke
Excludes
- Acute stroke (I63.9)
Clinical Validation Requirements
- Documentation of right-sided weakness
- Link to past cerebral infarction
Code-Specific Risks
- Incorrect use if no residuals are present
Coding Notes
- Ensure documentation clearly links the hemiparesis to the past cerebral infarction.
Z86.73 - Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits
Use when the patient has a history of stroke but no current residual deficits.
Applicable To
- History of stroke with no current deficits
Excludes
- Current residuals from past stroke (I69.3-)
Clinical Validation Requirements
- No current neurological deficits
- Clear documentation of past stroke
Coding Notes
Ensure documentation states there are no residual deficits.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
NIHSS score
R29.7Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting History of Cerebral Infarction to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code I69.351.
Impact
Clinical: Inaccurate patient history., Regulatory: Non-compliance with documentation standards., Financial: Potential claim denials.
Mitigation Strategy
Specify type and residuals of stroke.
Impact
Reimbursement: Incorrect coding may lead to denied claims., Compliance: Non-compliance with ICD-10 guidelines., Data Quality: Inaccurate patient records.
Mitigation Strategy
Switch to I69 or Z86.73 codes after the acute phase.
Impact
Using I63 codes post-acute phase.
Mitigation Strategy
Educate staff on proper code transition.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for History of Cerebral Infarction, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for History of Cerebral Infarction
Use these documentation templates to ensure complete and accurate documentation for History of Cerebral Infarction. These templates include all required elements for proper coding and billing.
Follow-up visit for past cerebral infarction
Specialty: NeurologyRequired Elements
- Date of initial stroke
- Type of stroke
- Current residuals
- Imaging results
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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