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Radiology Coding Alert - Spring 2012 Edition

Alert Details

Medicare and many commercial payors have specific policies in place for coverage of Magnetic Resonance Imaging and/or Magnetic Resonance Angiography of the Head and Brain. Appropriate documentation of the patient's symptoms and exam results is a key factor to prove the study is medically necessary.

Documentation for Stroke

• Document whether the stroke is hemorrhagic or non-hemorrhagic
• Identify the artery affected when reporting ischemic or non-hemorrhagic strokes
• Document whether or not there is an infarction (area of necrosis or tissue death due to obstruction of a blood vessel by a thrombus, embolus or a hemorrhagic or ischemic event)
• Document the site of the hemorrhage for hemorrhagic stroke
• Document any neurologic deficits associated with the acute CVA, regardless of whether or not the neurologic deficit resolves prior to discharge *

Documentation for Impending Stroke or TIA

• Impending cerebrovascular accident or attack (435.9)
• TIA or transient ischemic attack (435.9)
• If the TIA links to a specific precerebral artery, document the artery and the coder will assign a more specific diagnosis code (e.g. 433.10, TIA due to carotid stenosis)

Documentation for Stroke Symptoms

• If no definitive diagnosis has been established, document specific patient symptoms

Common Stroke Symptoms

• Alteration of mental status (780.97)
• Confusion (298.9)
• Confusion (298.9)
• Dizziness (780.4)
• Slurred speech (784.59)
• Aphasia (784.3)
• Paralysis (344.9)
• Numbness (782.0)
• Facial weakness (781.94)
• Weakness on one side of the body (780.79)
• Blurred vision (368.8) or double vision (368.2)
• Sudden, severe headache (784.0) **

Be sure to reference Medicare and commercial payor policies for head and/or brain MRI and MRA services as not all diagnoses are considered medically necessary.

If you have any questions regarding this notification, please contact your SVA Healthcare Services professional.

Resources:

* 2011 Official ICD-9-CM Guidelines for Coding and Reporting, Chapter 7: Diseases of Circulatory System, b. Cerebral infarction/stroke/cerebrovascular accident (CVA) http://www.cdc.gov/nchs/data/icd9/icd9cm_guidelines_2011.pdf

** Coding for Cerebral Infarction for the Record, Vol. 21, No. 21, P. 24 http://www.fortherecordmag.com/archives/110909p24.shtml