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. 2017 Jul 2;7(6):e015234. doi: 10.1136/bmjopen-2016-015234

Table 1.

Examples of coding from physician documentation of diagnostic impressions

Documentation ICD-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.