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Documentation Tip of the Week: Stroke for ICD-10

Posted on Wed, Sep 30, 2015
Documentation Tip of the Week: Stroke for ICD-10

Our weekly feature of documentation tips for clinicians.

By Timothy Brundage, MD

ICD-10 is coming October 1st! Are you ready?

Key points in the documentation of stroke:

  • Laterality & Site (identify affected vessel)
  • Etiology (occlusion, hemorrhage, thrombosis, stenosis)
  • Underlying conditions (HTN, Atrial Fibrillation, etc.)
  • List any alcohol, drug, tobacco use/abuse/dependence
  • List tobacco exposure (second hand, occupational)

Hemiplegia is a comorbidity/complication (CC)
  • Document if dominant side for ICD-10

Document “history of stroke” only in the PMHx portion

“Sequelae” of stroke is preferred if there is a manifestation due to current/previous stroke:
  • Hemiplegia, as a sequelae of stroke
  • Aphasia, as a sequelae of stroke
  • Ataxia, as a sequelae of stroke



Dr. Timothy Brundage is a hospitalist for EmCare at St. Petersburg General Hospital in St. Petersburg, Fla. Dr. Brundage earned his bachelor’s degree in chemistry and molecular biology at the University of Michigan, his M.D. at the Wayne State University School of Medicine and completed his residency in internal medicine at the University of South Florida College of Medicine. Subscribe to Dr. Brundage’s weekly documentation tips, or ask him about specific documentation issues, by emailing him at DrBrundage@gmail.com.

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