Table 1

Examples of coding from physician documentation of diagnostic impressions

DocumentationICD-10-CA codes*Interpretation of codes
Physician 1:
clear diagnosis		82F known AF, likely cardioembolic left hemispheric TIA. Differential includes seizures.
CT/CTA: no stroke, left MCA-M2 occlusion		G45.8 (MP)
Q R56.88 (OP)
I66.0 (OP)
I48.90 (OP)		Other transient cerebral ischaemic attacks and related syndromes
Seizure—queried
Occlusion and stenosis of MCA
AF, unspecified
Physician 2:
uncertainty		82F history of AF, transient aphasia and right arm weakness. Cerebral ischaemia vs seizure.
CT/CTA: no stroke, left MCA-M2 occlusion		R47.0 (MP)
R29.8 (OP)
Q I63.5 (OP)
Q R56.88 (OP)
I66.0 (OP)
I48.90 (OP)		Aphasia
Right arm weakness
Cerebral infarction—queried
Seizure—queried
Occlusion and stenosis of MCA
AF, unspecified
Physician 3:
lack of definite diagnosis		82F with AF, transient aphasia and right arm weakness.
CT/CTA: no stroke, left MCA-M2 occlusion		R47.0 (MP)
R29.8 (OP)
I66.0 (OP)
I48.90 (OP)		Aphasia
Right arm weakness
Occlusion and stenosis of MCA
AF, unspecified

  • *These represent real codes generated by a coding specialist in a tertiary care hospital based on the hypothetical patient information.

  • AF, atrial fibrillation; CT/CTA, CT and angiography; ICD-10-CA , International Classification of Disease 10th Canadian iteration; MCA-M2, middle cerebral artery, M2 branch, MP, main problem; OP, other problem; TIA, transient ischaemic attack.