Learn about accurate clinical documentation and medical coding for a History of Transient Ischemic Attack TIA. This guide covers diagnosis codes, ICD-10 codes specifically I67.9 for TIA, and best practices for healthcare professionals documenting a past TIA event. Find information on TIA diagnosis criteria, risk factors, and secondary prevention strategies related to a history of transient ischemic attack. Improve your understanding of medical coding guidelines, clinical documentation improvement CDI, and proper terminology for a History of TIA to ensure accurate patient records and optimal reimbursement.
Also known as
Cerebral infarction
History of TIA falls under cerebral infarction sequelae.
Transient cerebral ischemic attacks
This range covers current TIAs and related syndromes.
Personal history of transient ischemic attack
This code specifically represents a past TIA.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is the TIA current or in the past?
Current/Active TIA
Code as G45.9 Transient cerebral ischemia, unspecified
Past/History of TIA
Any residual neurological deficit?
When to use each related code
| Description |
|---|
| Transient neurological deficit |
| Amaurosis fugax |
| Vertebrobasilar insufficiency |
Coding TIA without laterality (right, left, or bilateral) or specific vascular territory impacts reimbursement and quality metrics.
Miscoding "Rule Out TIA" as confirmed TIA leads to inaccurate reporting and potential overtreatment. CDI clarification is crucial.
Confusing TIA with minor stroke can skew stroke registry data and impact quality reporting. Careful clinical validation needed.
Patient presents with a history of transient ischemic attack (TIA), also documented as a mini-stroke. The patient reports experiencing transient neurological deficits consistent with a TIA, including [specific symptoms e.g., right-sided weakness, aphasia, amaurosis fugax]. The onset of symptoms was [time of onset] and the duration was approximately [duration of symptoms]. Symptoms resolved completely within [timeframe of resolution, e.g., 24 hours]. Differential diagnosis included stroke, seizure, migraine with aura, and peripheral neuropathy. Risk factors for TIA assessed include hypertension, hyperlipidemia, diabetes mellitus, atrial fibrillation, smoking status, and family history of cerebrovascular disease. Current medications include [list medications]. Physical examination revealed [relevant findings e.g., normal neurological exam, carotid bruit]. Diagnostic workup to evaluate the etiology of the TIA included [list diagnostic tests e.g., carotid ultrasound, ECG, MRI brain]. Results of these tests were [summarize results]. The patient was educated on TIA symptoms, stroke risk factors, and the importance of seeking immediate medical attention if symptoms recur. A treatment plan was initiated, focusing on stroke prevention and includes [specific interventions, e.g., antiplatelet therapy with aspirin, management of hypertension, lifestyle modifications such as smoking cessation and diet changes]. Follow-up with neurology/cardiology was scheduled to further assess and manage stroke risk factors. ICD-10 code G45.9 Transient cerebral ischemic attack, unspecified, and CPT codes for evaluation and management services were documented for billing purposes. The patient demonstrates understanding of the diagnosis, treatment plan, and importance of adherence to prescribed medications and lifestyle modifications.