Need some guidance in coding the following for an annual assessment.
The patients 1st Stroke occurred 2016 – that resulted in the following code of I69.354 Hemiplegia and hemiparesis following a cerebral infarction affecting left non-dominant side
On 10/5/2018 the patient had a TIA/Cerebral infarct without any residual deficit. Per guideline we do not code both I69.354 and Z86.73 so how would I capture the recent TIA/infarct?
Thank you for any and all feedback.
Janet Norton RN, BSN, CPC, CRC, CCM
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The Z86.73 would cover both TIA/infarct. You can't code any code twice. There is no way to code it twice, the information would still be in the medical record.
Brenda Mohs, RHIT
Home Health & LTC Medical Coder
I misunderstood your question. You would code both I69.354 and Z86.73. Even though there is an Excludes 1 note, the two codes cover two different unrelated encounters so it is appropriate to code both.