ICD-10 Coding for Cerebrovascular Accident (CVA) Late Effects(I69.351, Z86.73)
Complete ICD-10-CM coding and documentation guide for Cerebrovascular Accident (CVA) Late Effects. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Cerebrovascular Accident (CVA) Late Effects
I69Primary Range
Sequelae of cerebrovascular disease
This range covers all late effects of cerebrovascular accidents, including hemiparesis, dysphagia, and other neurological deficits.
Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits
Used when there is a history of CVA without current residual deficits.
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 dominant hemiparesis as a sequela of a past cerebral infarction. |
|
| Z86.73 | Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits | Use when there is a documented history of CVA with 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 old CVA
Essential facts and insights about Cerebrovascular Accident (CVA) Late Effects
Primary ICD-10-CM Codes for old costovertebral angle
Decision Criteria
clinical Criteria
- Presence of right-sided weakness post-CVA
documentation Criteria
- Link between weakness and past CVA
Applicable To
- Right dominant hemiparesis due to past CVA
Excludes
- Acute cerebrovascular accident (I63.-)
Clinical Validation Requirements
- Documented right-sided weakness
- History of cerebral infarction
- Current physical exam findings
Code-Specific Risks
- Ensure laterality and dominance are specified
- Link deficit directly to past CVA
Coding Notes
- Ensure documentation specifies the side affected and the dominance of the patient.
Z86.73 - Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits
Use when there is a documented history of CVA with no current residual deficits.
Applicable To
- History of CVA without current deficits
Excludes
- Current deficits due to CVA (I69.-)
Clinical Validation Requirements
- Documented history of CVA
- Normal neurological exam
Coding Notes
Use this code only when the patient has no current symptoms related to the past CVA.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Personal history of cerebral infarction without residual deficits
Z86.73Differential 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 Cerebrovascular Accident (CVA) Late Effects 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 diagnosis and treatment planning., Regulatory: Non-compliance with coding standards., Financial: Potential claim denials.
Mitigation Strategy
Ensure documentation explicitly links deficits to CVA, Use templates to guide documentation
Impact
Reimbursement: Incorrect coding can lead to denied claims., Compliance: Non-compliance with ICD-10 guidelines., Data Quality: Inaccurate patient records and data reporting.
Mitigation Strategy
Use I69.- codes for late effects and Z86.73 for history without residuals.
Impact
Reimbursement: May result in incorrect DRG assignment., Compliance: Failure to meet documentation standards., Data Quality: Incomplete clinical data.
Mitigation Strategy
Always specify the affected side and dominance in the documentation.
Impact
Inadequate documentation linking deficits to past CVA.
Mitigation Strategy
Use structured templates and ensure clear linkage in documentation.
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 Cerebrovascular Accident (CVA) Late Effects, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Cerebrovascular Accident (CVA) Late Effects
Use these documentation templates to ensure complete and accurate documentation for Cerebrovascular Accident (CVA) Late Effects. These templates include all required elements for proper coding and billing.
Neurology Progress Note
Specialty: NeurologyRequired Elements
- Subjective complaints
- Objective findings
- Assessment linking deficit to past CVA
- Treatment plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
Need help with ICD-10 coding for Cerebrovascular Accident (CVA) Late Effects? Ask your questions below.