HCC Tips: Documenting a Past CVA

Recognizing it’s the dog days of August, we’re keeping it to just a few quick reminders about accurately assigning codes for patients with stroke. As you may recall, you should not code an active problem as “history of”. However, it is also not accurate to code certain diagnoses that occurred in the past as active, even though care is continuing for that condition. CVA is one such example.

An acute CVA represents a medical emergency that requires prompt medical treatment, and thus the code sets for this are used in the acute hospital or immediate post-acute care setting. A diagnosis of CVA with no supporting info and no related treatment plan does not support CVA as an acute event, but rather suggests history of CVA. Thus in the outpatient setting, CVA would not be an appropriate code.

When a neurologic deficit related to a past CVA is described as “history of” or “status post” (as in “history of CVA with right hemiparesis”) it should not be coded as current if there is no documentation to support the residual deficit as still being present.

Contrast these two diagnostic assessment examples:

“History of CVA with right hemiparesis” – The description supports both CVA and right hemiparesis as historical – and would be coded as Z86.73.

“Residual right hemiparesis due to past CVA” – This description supports right hemiparesis as current and due to past CVA – coded as I69.351. In this case, the documentation should include a physical exam confirming the hemiparesis is present currently.

Thus, it is important to note that codes for sequelae/residual late effects cannot be assigned based on the status of the condition in the past, rather, codes are assigned based on current status.

  • CVA is an acute condition diagnosis, coded during hospital or post-acute/SNF stays.
  • In the outpatient setting, code the sequela related to CVA (such as hemiplegia and/or hemiparesis) from 169 –
  • If there are no sequela related to the stroke event, code history of stroke Z86.73.

Remember, the “Evaluation and Management Services Guide” issued by the Department of Health and Human Services and the Centers for Medicare & Medicaid Services (CMS) advises:

“Clear and concise medical record documentation is critical to providing patients with quality care and is required in order for providers to receive accurate and timely payment for furnished services. Medical records chronologically report the care a patient received and are used to record pertinent facts, findings and observations about the patient’s health history. Medical record documentation assists physicians and other healthcare professionals in evaluating and planning the patient’s immediate treatment and monitoring the patient’s healthcare over time.”

Providers should accurately select ICD-10 diagnoses and patient conditions that co-exist at the time of a face to face encounter or visit, require or affect patient care treatment or management, and are documented in the patient medical record.1

In upcoming issues, we’ll continue to provide info on commonly coded diagnoses that are prone to coding confusion.

Let us know what diagnoses are causing you problems, and we’ll do our best to help!

Thanks to all for your hard work on this – it IS making a BIG difference!

  1. CMS Manual System, Pub. 100-16, Transmittal 116, and Medicare Managed Care Manual, Chapter 7, Risk Adjustment, Section 40 – Roles and Responsibilities of Plan Sponsors