Find information on History of Stroke with Residual Deficits including clinical documentation, medical coding (ICD-10 I69.4), and healthcare resources. Learn about post-stroke care, managing neurological deficits, rehabilitation therapies, and long-term effects. This resource offers guidance for healthcare professionals on accurate diagnosis reporting and patient management for stroke survivors with persistent impairments. Explore resources on secondary stroke prevention and improving quality of life after stroke.
Also known as
Sequelae of cerebrovascular disease
Conditions resulting from a previous stroke.
Cerebrovascular diseases
Covers various cerebrovascular conditions, including stroke.
Personal history of stroke
Indicates a past stroke, useful for context but not the primary diagnosis.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the stroke ischemic?
Yes
Current deficits?
No
Is the stroke hemorrhagic?
When to use each related code
Description |
---|
Stroke with lasting weakness |
Stroke with aphasia |
Stroke with dysphagia |
Incomplete documentation of stroke laterality (right, left, or bilateral) impacts code specificity and reimbursement.
Vague descriptions of residual deficits (e.g., "weakness") lead to inaccurate code assignment and affect quality metrics.
Lack of clarity differentiating acute stroke from chronic sequelae can lead to incorrect coding and impact patient care.
Patient presents with a history of cerebrovascular accident (CVA), confirmed by previous imaging (specify type and date if available), resulting in residual neurological deficits. The patient reports persistent symptoms consistent with post-stroke sequelae, including (specify affected areas such as motor function, sensory perception, cognitive abilities, speech, swallowing, vision, balance, and emotional status). Assessment reveals (describe specific findings such as hemiparesis, hemiplegia, aphasia, dysarthria, ataxia, sensory loss, cognitive impairment, emotional lability, dysphagia, visual field deficits, or other relevant observations). These deficits impact the patient's activities of daily living (ADLs) and instrumental activities of daily living (IADLs), requiring (specify level of assistance needed and any assistive devices used). Current medications include (list all medications, including those related to stroke prevention, management of comorbidities, and symptom control). The patient's medical history also includes (list relevant comorbidities such as hypertension, diabetes, hyperlipidemia, atrial fibrillation, or other cardiovascular risk factors). The current treatment plan focuses on managing residual symptoms, maximizing functional recovery through (specify therapies such as physical therapy, occupational therapy, speech therapy, cognitive rehabilitation), and secondary stroke prevention. Patient education provided on lifestyle modifications including diet, exercise, and medication adherence. Follow-up scheduled for (specify date and reason). Diagnosis: History of stroke (I69.3), residual neurological deficits (specify relevant ICD-10 codes for specific deficits). Prognosis: (describe anticipated functional outcome based on current deficits and response to therapy). Plan to monitor for complications such as recurrent stroke, depression, and pain management.