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Question: During a patient鈥檚 annual wellness exam, my provider documented 鈥渁taxia with history of stroke.鈥� Should I use codes R27.0 and Z86.73 on my claim for this visit?

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Answer: Not exactly. By themselves, these codes represent two conditions: ataxia, coded to R27.0 (Ataxia, unspecified), and history of stroke, coded to Z86.73 (Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits). However, this is not the best way to report this scenario.

To understand why, first look up 鈥渁taxia鈥� in the index. Under that, you will see the sub-entry 鈥渇ollowing,鈥� which leads to subsequent sub-entries for 鈥渃erebrovascular disease鈥� and, finally, 鈥渃erebral infarction鈥� (i.e., ischemic stroke). At that point, the ICD-10-CM index directs you to I69.393 (Ataxia following cerebral infarction). When the provider mentions that the patient exhibits ataxia and has a history of stroke, they are establishing a connection between these two medical conditions. So, in this instance, the ataxia is a residual effect from the stroke, which is no longer in its acute phase. The patient isn鈥檛 consulting this provider for immediate stroke symptoms, especially if they鈥檙e attending their yearly wellness check-up. The remaining issue they鈥檙e dealing with is a lack of coordination.

It鈥檚 important to use the index as a starting point and follow the trail to the correct code. The correct code for this happens to be a combination code, I69.393. Even if you knew from the documentation that the ataxia was sequela of the stroke, you might incorrectly follow typical sequela coding, which would be whatever your condition is, potentially R27.0 followed by the initial code with the 7^th character. However, Excludes1 notes following R27.0 and Z86.73 reinforce that I69.393 is the better choice. The Excludes1 note following R27.0 states 鈥渁taxia following cerebrovascular disease (I69. with final characters -93),鈥� and an Excludes1 note following Z86.73 states 鈥渟equelae of cerebrovascular disease (I69.-).鈥�

Lindsey Bush, BA, MA, CPC, Development Editor, AAPC