Cerebrovascular accident (CVA), also known as stroke, is a leading cause of disability and death worldwide. In medical coding, accurately assigning the ICD-10-CM code for CVA is essential for documentation, reimbursement, and patient care.
This guide will explain how to code CVA diagnosis in ICD-10-CM, including acute stroke, sequelae (late effects), and history of stroke without residual deficits.
What is a CVA (Stroke)?
A CVA occurs when blood flow to part of the brain is interrupted due to either a blocked vessel (ischemic stroke) or a ruptured vessel (hemorrhagic stroke). The loss of oxygen supply causes rapid neurological injury.
ICD-10-CM Codes for CVA Diagnosis
The ICD-10-CM system classifies cerebrovascular diseases in the code range I60–I69. Coding CVA correctly requires identifying whether the patient is experiencing an acute stroke, sequelae (residual effects), or a past history of stroke without late effects.
1. Acute Stroke (Current Event) – ICD-10-CM Codes
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I60.–: Nontraumatic subarachnoid hemorrhage
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I61.–: Nontraumatic intracerebral hemorrhage
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I62.–: Other nontraumatic intracranial hemorrhage
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I63.–: Cerebral infarction (ischemic stroke)
👉 Example: I63.412 – Cerebral infarction due to embolism of left middle cerebral artery
2. Sequelae of Stroke (Late Effects) – ICD-10-CM Codes
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I69.–: Sequelae of cerebrovascular disease
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Example: I69.351 – Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side
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Use this category when the patient has residual deficits from a prior stroke, such as hemiplegia, speech difficulty, or cognitive impairment.
3. History of Stroke Without Residual Deficits – ICD-10-CM Code
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Z86.73: Personal history of transient ischemic attack (TIA) and cerebral infarction without residual deficits
This is used when the patient had a stroke in the past but currently has no lingering neurological symptoms. It helps flag the patient as high risk for future events, even though there are no ongoing impairments.
Key Documentation Tips for Stroke Coding in ICD-10-CM
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Identify Stroke Type – Ischemic vs. hemorrhagic (or unspecified if documentation is unclear).
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Specify Laterality & Dominance – Indicate left vs. right and whether it affects the dominant or nondominant side.
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Clarify Residual Deficits vs. No Deficits – Use I69.– for sequelae and Z86.73 for history without deficits.
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Determine Timeline – Is this an acute stroke, past stroke with sequelae, or remote history without effects?
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Document Related Conditions – Capture comorbidities such as hypertension, diabetes, or atrial fibrillation.
Common Stroke Coding Scenarios in ICD-10-CM
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Acute ischemic stroke, left MCA territory → I63.412
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Old CVA with right-sided hemiplegia → I69.351
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History of stroke, no residuals → Z86.73
Comparison Table: Acute Stroke vs. Sequelae vs. History in ICD-10-CM
Why Accurate ICD-10-CM Coding for CVA Matters
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Better Patient Care: Clear documentation supports treatment planning.
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Compliance & Reimbursement: Proper coding ensures correct DRG assignment.
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Quality Reporting: Programs like CMS and The Joint Commission rely on accurate stroke coding.
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Public Health Data: Research and statistics on stroke outcomes depend on precise ICD-10-CM usage.
Final Thoughts
Correctly assigning the ICD-10-CM code for CVA requires distinguishing between an acute stroke, sequelae, or past history without late effects. For providers, this means documenting clearly; for coders, it means applying guidelines accurately. Together, both steps ensure compliance, accurate reimbursement, and better patient outcomes.
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