Cerebrovascular Accident (CVA)

Patients that suffered from a CVA?*

Yes

Acute cerebrovascular accident (CVA)

Cerebrovascular accidents (CVAs), strokes or brain infarcts are a medical emergency. Quick treatment is needed, patients should be sent to ER.4 The correct code for an acute episode of the condition is I63.9.1 If this code is used in an office setting, documentation must support the acute episode. The physician may require additional testing to establish the diagnosis, code signs and symptoms if the diagnosis is uncertain.

Speech and language deficits

• Aphasia I69.320

• Dysphasia I69.321

• Dysarthria I69.322

Monoplegia of lower limbs

• Right dominant side I69.341

• Left dominant side I69.342

• Right non-dominant side I69.343

• Left non-dominant side I69.344

• Unspecified side I69.349

No

Many common medical conditions can increase the chance of suffering a CVA. These are hypertension, high cholesterol, heart disease, diabetes, others. If the patient had a transient ischemic attack (TIA) already, the risk of having a CVA is even higher.2

Hemiparesis or hemiplegia

• Right dominant side I69.351

• Left dominant side I69.352

• Right non-dominant side I69.353

• Left non-dominant side I69.354

• Unspecified side I69.359

Other paralytic syndromes

• Right dominant side I69.361

• Left dominant side I69.362

• Right non-dominant side I69.363

• Left non-dominant side I69.364

• Unspecified side I69.369

• Use additional code for: Paraplegia G82.20 or Quadriplegia G82.50

Sequelae management3

• Rehabilitation like physical therapy and swallowing and respiratory therapy

• Drug therapy

• Psychological treatment such as antidepressant and counseling

• Skin breakdown prevention

• Limb contractures prevention

• Other treatments

Stroke is the fifth leading cause of death in the United States and is a major cause of serious disability for adults. About 795,000 people in the United States have a stroke each year.2

The sequela may be apparent early, or it may occur months or years later. There is no timeframe to code a sequela5

Monitor periodically these conditions and their plan of treatment. Some patients do not adhere to medications, diet or care plan. We recommend scheduling one face-to-face visit before July 1st, and one before December 31st.

References and Additional Notes:

* This tool is not intended to diagnose, evaluate or treat patients. Each provider is responsible for the clinical and diagnostic decisions pertinent to their patient’s medical care. Always refer to the ICD-10-CM codebook for correct coding and more information about coding guidelines at: cdc.gov/nchs/icd/icd10cm.htm

1. CMS-HCC scores are based on CMS’ 2020 community-nondual-aged enrollees

2. CDC Accidents Cerebrovascular 2016. Excerpted: https://www.cdc.gov/stroke/risk_factors.htm

3. American Stroke Association. Let’s talk about Complications after stroke. Excerpted: https://www.strokeassociation.org/idc/groups/stroke-public/@wcm/@hcm/documents/downloadable/ucm_309717.pdf

4. US National Library of Medicine. Stroke. Excerpted: https://medlineplus.gov/ency/article/000726.htm

5. CMS. ICD-10-CM Official Guidelines for Coding and Reporting FY 2021

HCCs: Cerebrovascular Accident (CVA)