Documentation and Coding Tips
Why It Matters
Cerebrovascular Accident (CVA)/Stroke and Myocardial Infarction (MI) are among the most frequently miscoded conditions. Because these diagnoses can significantly impact the accurate representation of a patient’s disease burden, documentation should clearly reflect the patient’s current clinical status, ongoing treatment, monitoring activities, and any residual effects. Comprehensive and precise documentation supports accurate ICD-10-CM code assignment and helps ensure the patient’s true health complexity and care needs are appropriately captured.
Please refer to the tables below for proper documentation and coding guidance.
Cerebrovascular Accident (CVA)/Stroke Sequelae
| Acute inpatient CVA | I63.- | Typically assigned in the inpatient/emergency setting |
|---|---|---|
| Late effects/Sequelae of Stroke | I69.3- | Document and link deficit to prior CVA. |
| Prior CVA with no residual deficits | Z86.73 | Personal history of stroke without residual effects |
Documentation Best Practices:
- Clearly document:
- The type and history of the stroke
- Specific residual deficits
- The relationship between the deficit and the prior cerebrovascular event
- Functional impact on daily activities
- Strong documentation examples include:
- “Left hemiparesis due to prior CVA.”
- “Aphasia secondary to old cerebral infarction.”
- “Late effect of stroke.”
- “Gait instability related to prior stroke.”
Continue documenting active deficits annually until the patient has returned to pre-stroke baseline function.
Myocardial Infarction (MI)
| Scenario | ICD-10-CM Category | Documentation Tip |
|---|---|---|
| Acute MI within 4 weeks (28 days) | I21.- | Specify STEMI, NSTEMI, Type 1, or other MI type |
| Subsequent MI within 4 weeks of initial MI | I22.- + I21.- | Both codes may be required |
| Complications following MI | I23.- | Must be coded with I21/I22 when applicable |
| Old/Healed MI | I25.2 | Prior MI, no active symptoms |
| History of MI/circulatory disease | Z86.79 | Use only when resolved and no active management remains |
Documentation Best Practices:
- Clearly document:
- Document Acute MI as active when the patient is within 28 days of the event and remains in the acute phase of treatment or is undergoing titration of guideline-directed medical therapy (GDMT).
- Clearly identify whether the MI is acute, subsequent, or old/healed.
- Document ongoing management and treatment
- Strong documentation examples include:
- “Acute NSTEMI diagnosed 10 days ago, currently under active management.”
- “Old myocardial infarction, stable without active symptoms.”
- “History of STEMI with ongoing secondary prevention therapy.”
- “Subsequent MI occurring within 4 weeks of initial infarction.”
- “Patient remains on aspirin, statin, and beta blocker following MI.”