Stroke

Diagnosis: Stroke / CVA

Applicable for MSDRGs: 061, 062, 063, 064, 065, 066, 067, 068, 069

MD documentation should address:

1. Presenting symptoms: abnormal neurological findings as compared to pt’s baseline
2. CXR findings (i.e. pulmonary edema; pleural effusions; emphysema; infiltrates; bronchiectasis; cardiomegaly, etc)
3. CT/MRI Findings: location of cerebral hemorrhage or infarction; occlusion and stenosis; other abnormal findings
4. EKG: new findings and subsequent changes
5. Evidence of SIRS: Must have at least 2 of the following:
   • Tachycardia: Pulse>90
   • Tachypnea: RR >20
   • Temp >100.4 (38C) or <96.8 (36C)
   • WBC >12,000 or <4,000 or >10% bands
6. Acute Ischemic stroke: affected artery(ies) and treatment (thrombolytic agent)
7. Cerebral artery occlusion/stenosis and associated cerebral infarction with residual affects
8. Cause of cerebral hemorrhage if known
9. Any medical conditions that are affecting the current or future Rehab plans
10. Treatment with medications, procedures or therapies

Go Back to the Diagnoses List