Call it a stroke, CVA, or cerebral infarction; no matter what you call it, a stroke can have devastating consequences for the patient, and the ‘greater specificity’ of ICD-10 is very evident here. Care must be taken to document explicitly in ICD-10-appropriate language. Documentation requirements now include the etiology of the CVA, the vessel affected, and the laterality of the stroke.
We may all be aware that a large percentage of strokes are ischemic; unfortunately, ischemic/ischemia is no longer sufficient documentation for coding a CVA. The ischemia caused brain tissue to be starved of oxygen and nutrients, but what caused the ischemia in the first place? Occlusion? Embolism? Thrombosis? Whatever the cause, documentation is the key to insuring the most accurate coding of the chart (and avoiding a query!)
Remember, on discharge notes for inpatient services, nearly all diagnoses that are qualified as possible, probable, likely, suspected, and similar terms that indicate uncertainty allow the coder to code the condition as if it were established. This means documentation such as “Acute left MCA stroke, likely embolic” is adequate documentation for query avoidance.