ICD-10 Coding for History of Cerebrovascular Accident(Z86.73, I69.-)
Complete ICD-10-CM coding and documentation guide for History of Cerebrovascular Accident. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to History of Cerebrovascular Accident
Z86.73Primary Range
Personal history of transient ischemic attack (TIA) and cerebral infarction without residual deficits
Used when there is a history of TIA or cerebral infarction without any current residual deficits.
Sequelae of cerebrovascular disease
Used when there are residual deficits from a previous cerebrovascular accident.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| Z86.73 | Personal history of transient ischemic attack (TIA) and cerebral infarction without residual deficits | Use when there is a documented history of TIA or cerebral infarction with no residual deficits. |
|
| I69.- | Sequelae of cerebrovascular disease | Use when there are residual deficits from a previous CVA. |
|
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 cerebrovascular accident
Essential facts and insights about History of Cerebrovascular Accident
Primary ICD-10-CM Codes for history of cerebrovascular accident
Decision Criteria
clinical Criteria
- No residual neurological deficits present
coding Criteria
- History of TIA or cerebral infarction documented
Applicable To
- History of TIA
- History of cerebral infarction without residuals
Excludes
- Current cerebrovascular accident
- Residual deficits from previous CVA
Clinical Validation Requirements
- No neurological deficits on examination
- Negative imaging for acute event
Code-Specific Risks
- Incorrectly coding when residuals are present
Coding Notes
- Ensure no residual deficits are present before using this code.
I69.- - Sequelae of cerebrovascular disease
Use when there are residual deficits from a previous CVA.
Applicable To
- Residual deficits from previous CVA
Excludes
- Acute cerebrovascular accident
Clinical Validation Requirements
- Documented residual deficits linked to past CVA
- Imaging showing old infarct
Coding Notes
Ensure residual deficits are clearly documented and linked to the past CVA.
Differential 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 Cerebrovascular Accident to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code Z86.73.
Impact
Clinical: Inaccurate clinical records, Regulatory: Potential audit issues, Financial: Incorrect billing
Mitigation Strategy
Specify if residuals are present, Use appropriate codes
Impact
Reimbursement: May result in incorrect reimbursement, Compliance: Non-compliance with coding guidelines, Data Quality: Inaccurate patient records
Mitigation Strategy
Use I69.- codes for residual deficits
Impact
Using Z86.73 when residuals are present can lead to audits.
Mitigation Strategy
Ensure thorough documentation of residuals and use I69.- codes appropriately.
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 Cerebrovascular Accident, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for History of Cerebrovascular Accident
Use these documentation templates to ensure complete and accurate documentation for History of Cerebrovascular Accident. These templates include all required elements for proper coding and billing.
Follow-up for past CVA with no residuals
Specialty: NeurologyRequired Elements
- Patient history
- Neurological exam
- Imaging results
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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