Coding, Classification & Reimbursement

  • 1.  Acute Stroke

    Posted 05-30-2018 17:37
    I have an inpatient who came in with right-sided weakness and slurred speech. This progressed to paralysis of the right arm and aphasia.  The patient had an MRI that states, "Restricted diffusion consistent with geographic ischemic infarcts within the posterior lateral left insular cortex, left temporal lobe, and anterior left parietal lobe. Punctate areas of restricted diffusion noted within the posterior right frontal lobe–deep white matter, and the left occipital lobe. These findings in different vascular distributions are consistent with an embolic event."

    The physician diagnosed "Acute Stroke."  Since the Posterior Insular Cortex, large portions of the Frontal, Parietal, and Temporal Lobe are supplied by the Middle Cerebral Artery and the Occipital Lobe is supplied by the Posterior Cerebral Artery, could this be coded as I63.413 - Cerebral infarction due to embolism of bilateral middle cerebral arteries - and I63.432 - Cerebral infarction due to embolism of the left posterior cerebral artery - for the Occipital Lobe?

    Coding Clinic Third Quarter 2014: Page 5 states, "It is appropriate to utilize imaging reports to provide greater specificity of the anatomic site as documented by the physician. Therefore, if a patient is diagnosed with a cerebral infarction or hemorrhagic stroke, it would be appropriate to utilize the imaging report to determine the location of the stroke or infarction."

    If the specific vessel is not documented in the report, would be appropriate to code a specific vessel? This Coding Clinic was not clear.

    Any advice would be greatly appreciated!
    Thank you!

    Kayla Hill, RHIA
    Director of Health Information/Privacy/CDI