Q&A: Reporting stroke, seizure in ICD-10-CM without pre-existing disorder

Q: Is there ICD-10-CM sequencing guidance for a patient who had a hemorrhagic stroke and then a seizure without a pre-existing seizure disorder? Would it be appropriate to report epilepsy, and are there any inclusion terms we should be aware of?

A: The 2021 ICD-10-CM Alphabetic Index contains inclusion terms for code G40.4 (other generalized epilepsy and epileptic syndromes). “Grand mal seizure not otherwise specified” is included in the term epilepsy. “Non-specific tonic clonic seizures” is also an inclusion term. So, either term directs coders to ICD-10-CM code G40.4. 

Clinically, epilepsy is diagnosed based on the occurrence of two or more seizures, and this patient reportedly has no history of seizure activity. Seizures do not get classified as epilepsy unless the seizures are recurrent. Convulsions (reported with a code from ICD-10-CM category R56) contain an Excludes1 note for epileptic convulsions and seizures, and vice versa.

The opportunity would be to clarify the type of seizure with the provider through the query process.

You’ll want to determine the circumstances of how the hemorrhage started. If trauma related, ICD-10-CM code R56.1 (post-traumatic seizures) may be appropriate, depending on the circumstances outlined in the documentation.

Editor’s Note: Dawn Valdez, RN, LNC, CCDS, CDI education specialist and CDI Boot Camp instructor for HCPro in Middleton, Massachusetts, answered this question for ACDIS. For information, contact her at dvaldez@hcpro.com.

This answer was provided based on limited information. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.