From the Division of Neurology, Department of Medicine, the Duke Center
for Cerebrovascular Disease, and the Center for Clinical Health Policy
Research, Duke University, Durham, NC, and the Division of Neurology, Durham
Department of Veterans Affairs Medical Center, Durham, NC.
Correspondence to Larry B. Goldstein, MD, Box 3651, Duke University Medical Center, Durham, NC 27710. E-mail golds004{at}mc.duke.edu
Background and Purpose—Discharge
ICD-9-CM (International Classification of Diseases, 9th
Revision, Clinical Modification) codes have been used to
identify patients with acute stroke for epidemiological, quality of
care, and cost studies. The aim of this study was to determine if the
accuracy of the primary ICD-9-CM codes for ischemic stroke is
improved by modifier codes and how specific codes reflect stroke
subtype diagnoses.
Methods—Available hospital charts for all patients discharged
from a single hospital between May 1995 and June 1997 with ICD-9-CM
codes 433 (occlusion and stenosis of precerebral arteries), 434
(occlusion of cerebral arteries), or 436 (acute but ill-defined
cerebrovascular disease) listed in the first position were reviewed.
The primary discharge diagnosis was verified, and a presumed stroke
subtype was assigned on the basis of information provided in the
medical record.
Results—Charts were available for 175 of the 198 identified
patients (88%). Of these, 61% had an acute ischemic stroke
(code 433, 4%; 434, 82%; 436, 79%) with the remaining patients
having other conditions. Of the 130 patients with a modifier code
indicating cerebral infarction, 79% had an acute stroke; of the 45
patients with a modifier code indicating an absence of cerebral
infarction, 7% had acute stroke (sensitivity, 0.97; specificity,
0.60). The codes with the highest proportions of ischemic
stroke cases were 434.11 (embolic occlusion of cerebral arteries with
infarction, 85%), 434.91 (unspecified occlusion of precerebral
arteries with infarction, 82%), and 436 (79%), with a combined
sensitivity of 0.81 and specificity of 0.90. On review, 73% of
patients with code 434.11 had embolic strokes, and 47% of those with
code 436 had an identified stroke cause. Of patients with code 434.91,
39% had stroke of uncertain cause, 25% "lacunar," 17%
atherothrombosis, and 15% embolism.
Conclusions—Despite the use of modifier codes, 15% to 20% of
patients with the indicated primary ICD-9-CM codes have conditions
other than acute ischemic stroke. Although the proportion of
patients with acute stroke increased from 61% to 79% with the use of
modifier codes, the inclusion of modifier codes did not have an
appreciable effect on the accuracy of the coding if patients with code
433 are excluded. Assignment of presumed ischemic stroke
subtype is particularly inaccurate.
© 1998 American Heart Association, Inc.
Original Contributions
Accuracy of ICD-9-CM Coding for the Identification of Patients With Acute Ischemic Stroke
Effect of Modifier Codes
Key Words: classification • epidemiology • stroke, ischemic • diagnosis
This article has been cited by other articles:
 |
|
 |
|
  N. Agrawal, S. C. Johnston, Y. W. Wu, S. Sidney, and H. J. Fullerton Imaging Data Reveal a Higher Pediatric Stroke Incidence Than Prior US Estimates Stroke, November 1, 2009; 40(11): 3415 - 3421. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. H. Lichtman, N. B. Allen, Y. Wang, E. Watanabe, S. B. Jones, and L. B. Goldstein Stroke Patient Outcomes in US Hospitals Before the Start of the Joint Commission Primary Stroke Center Certification Program Stroke, November 1, 2009; 40(11): 3574 - 3579. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
E. Perkins, J. Stephens, H. Xiang, and W. Lo The Cost of Pediatric Stroke Acute Care in the United States Stroke, August 1, 2009; 40(8): 2820 - 2827. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. H. Lichtman, S. B. Jones, E. Watanabe, N. B. Allen, Y. Wang, V. J. Howard, and L. B. Goldstein Elderly Women Have Lower Rates of Stroke, Cardiovascular Events, and Mortality After Hospitalization for Transient Ischemic Attack Stroke, June 1, 2009; 40(6): 2116 - 2122. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
C.-H. Tang, C.-S. Wu, T.-H. Lee, S.-T. Hung, C.-Y. C. Yang, C.-H. Lee, and P.-H. Chu Preeclampsia-Eclampsia and the Risk of Stroke Among Peripartum in Taiwan Stroke, April 1, 2009; 40(4): 1162 - 1168. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 C. D Bushnell, M. Jamison, and A. H James Migraines during pregnancy linked to stroke and vascular diseases: US population based case-control study BMJ, March 10, 2009; 338(mar10_2): b664 - b664. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 W. Lo, J. Stephens, and S. Fernandez Pediatric Stroke in the United States and the Impact of Risk Factors J Child Neurol, February 1, 2009; 24(2): 194 - 203. [Abstract] [PDF]
|
|
|
|
|
|
G. Saposnik, T. Jeerakathil, D. Selchen, A. Baibergenova, V. Hachinski, M. K. Kapral, and for the Stroke Outcome Research Canada (SORCan) Wo Socioeconomic Status, Hospital Volume, and Stroke Fatality in Canada Stroke, December 1, 2008; 39(12): 3360 - 3366. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
G. Saposnik, R. Cote, S. Phillips, G. Gubitz, N. Bayer, J. Minuk, S. Black, and for the Stroke Outcome Research Canada (SORCan) Wo Stroke Outcome in Those Over 80: A Multicenter Cohort Study Across Canada Stroke, August 1, 2008; 39(8): 2310 - 2317. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 G. Saposnik, A. Baibergenova, M. O'Donnell, M. D. Hill, M. K. Kapral, V. Hachinski, and On behalf of the Stroke Outcome Research Canada (S Hospital volume and stroke outcome: Does it matter? Neurology, September 11, 2007; 69(11): 1142 - 1151. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
N. Janjua, A. Nasar, J. K. Lynch, and A. I. Qureshi Thrombolysis for Ischemic Stroke in Children: Data From the Nationwide Inpatient Sample Stroke, June 1, 2007; 38(6): 1850 - 1854. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
D. M. Bravata, S.-Y. Ho, T. P. Meehan, L. M. Brass, and J. Concato Readmission and Death After Hospitalization for Acute Ischemic Stroke: 5-Year Follow-Up in the Medicare Population Stroke, June 1, 2007; 38(6): 1899 - 1904. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
I. L. Katzan, N. V. Dawson, C. L. Thomas, M. E. Votruba, and R. D. Cebul The cost of pneumonia after acute stroke Neurology, May 29, 2007; 68(22): 1938 - 1943. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 E. Onukwugha and C. D. Mullins Racial Differences in Hospital Discharge Disposition among Stroke Patients in Maryland Med Decis Making, May 1, 2007; 27(3): 233 - 242. [Abstract] [PDF]
|
|
|
|
|
|
N. E. Mayo, L. Nadeau, S. S. Daskalopoulou, and R. Cote The evolution of stroke in Quebec: A 15-year perspective Neurology, April 3, 2007; 68(14): 1122 - 1127. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
G. Saposnik, A. Baibergenova, N. Bayer, and V. Hachinski Weekends: A Dangerous Time for Having a Stroke? Stroke, April 1, 2007; 38(4): 1211 - 1215. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. J. Shen and E. L. Washington Disparities in Outcomes Among Patients With Stroke Associated With Insurance Status Stroke, March 1, 2007; 38(3): 1010 - 1016. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
M. R. Golomb, B. P. Garg, and L. S. Williams Accuracy of ICD-9 Codes for Identifying Children With Cerebral Sinovenous Thrombosis J Child Neurol, January 1, 2007; 22(1): 45 - 48. [Abstract] [PDF]
|
|
|
|
 |
|
 E. T. Rhodes, L. M.B. Laffel, T. V. Gonzalez, and D. S. Ludwig Accuracy of Administrative Coding for Type 2 Diabetes in Children, Adolescents, and Young Adults Diabetes Care, January 1, 2007; 30(1): 141 - 143. [Full Text] [PDF]
|
|
|
|
|
|
M. R. Golomb, B. P. Garg, C. Saha, and L. S. Williams Accuracy and yield of ICD-9 codes for identifying children with ischemic stroke Neurology, December 12, 2006; 67(11): 2053 - 2055. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
K. Lakshminarayan, C. A. Solid, A. J. Collins, D. C. Anderson, and C. A. Herzog Atrial Fibrillation and Stroke in the General Medicare Population: A 10-Year Perspective (1992 to 2002) Stroke, August 1, 2006; 37(8): 1969 - 1974. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 S. S. Waikar, R. Wald, G. M. Chertow, G. C. Curhan, W. C. Winkelmayer, O. Liangos, M.-A. Sosa, and B. L. Jaber Validity of International Classification of Diseases, Ninth Revision, Clinical Modification Codes for Acute Renal Failure J. Am. Soc. Nephrol., June 1, 2006; 17(6): 1688 - 1694. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. B. Low, L. Bielory, A. I. Qureshi, V. Dunn, D. F.E. Stuhlmiller, and D. A. Dickey The Relation of Stroke Admissions to Recent Weather, Airborne Allergens, Air Pollution, Seasons, Upper Respiratory Infections, and Asthma Incidence, September 11, 2001, and Day of the Week Stroke, April 1, 2006; 37(4): 951 - 957. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
H. F. McGruder, J. B. Croft, and Z.-J. Zheng Characteristics of an "Ill-Defined" Diagnosis for Stroke: Opportunities for Improvement Stroke, March 1, 2006; 37(3): 781 - 789. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
B. T. Bateman, H. C. Schumacher, B. Boden-Albala, M. F. Berman, J.P. Mohr, R. L. Sacco, and J. Pile-Spellman Factors Associated With In-Hospital Mortality After Administration of Thrombolysis in Acute Ischemic Stroke Patients: An Analysis of the Nationwide Inpatient Sample 1999 to 2002 Stroke, February 1, 2006; 37(2): 440 - 446. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
G. A. Wellenius, J. Schwartz, and M. A. Mittleman Air Pollution and Hospital Admissions for Ischemic and Hemorrhagic Stroke Among Medicare Beneficiaries Stroke, December 1, 2005; 36(12): 2549 - 2553. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
R. A. Kokotailo and M. D. Hill Coding of Stroke and Stroke Risk Factors Using International Classification of Diseases, Revisions 9 and 10 Stroke, August 1, 2005; 36(8): 1776 - 1781. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
D. L. Brown, L. D. Lisabeth, C. Roychoudhury, Y. Ye, and L. B. Morgenstern Recurrent Stroke Risk Is Higher Than Cardiac Event Risk After Initial Stroke/Transient Ischemic Attack Stroke, June 1, 2005; 36(6): 1285 - 1287. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
P. Spolaore, S. Brocco, U. Fedeli, C. Visentin, E. Schievano, F. Avossa, G. Milan, V. Toso, D. Vanuzzo, L. Pilotto, et al. Measuring Accuracy of Discharge Diagnoses for a Region-Wide Surveillance of Hospitalized Strokes Stroke, May 1, 2005; 36(5): 1031 - 1034. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
V. C. Douglas, D. C. Tong, L. A. Gillum, S. Zhao, L. M. Brass, J. Dostal, and S. C. Johnston Do the Brain Attack Coalition's criteria for stroke centers improve care for ischemic stroke? Neurology, February 8, 2005; 64(3): 422 - 427. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
L. B. Goldstein, G. P. Samsa, D. B. Matchar, and R. D. Horner Charlson Index Comorbidity Adjustment for Ischemic Stroke Outcome Studies Stroke, August 1, 2004; 35(8): 1941 - 1945. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 H. J. Fullerton, R. J. Adams, S. Zhao, and S. C. Johnston Declining stroke rates in Californian children with sickle cell disease Blood, July 15, 2004; 104(2): 336 - 339. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
L. D. Lisabeth, C. Roychoudhury, D. L. Brown, and S. R. Levine Do gender and race impact the use of antithrombotic therapy in patients with stroke/TIA? Neurology, June 22, 2004; 62(12): 2313 - 2315. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 D. J. Gladstone, M. K. Kapral, J. Fang, A. Laupacis, and J. V. Tu Management and outcomes of transient ischemic attacks in Ontario Can. Med. Assoc. J., March 30, 2004; 170(7): 1099 - 1104. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. B. Christian, K. L. Lapane, and R. S. Toppa Racial Disparities in Receipt of Secondary Stroke Prevention Agents Among US Nursing Home Residents Stroke, November 1, 2003; 34(11): 2693 - 2697. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. L. Seliger, D. L. Gillen, D. Tirschwell, H. Wasse, B. R. Kestenbaum, and C. O. Stehman-Breen Risk Factors for Incident Stroke among Patients with End-Stage Renal Disease J. Am. Soc. Nephrol., October 1, 2003; 14(10): 2623 - 2631. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
D. M. Bravata, S.-Y. Ho, L. M. Brass, J. Concato, J. Scinto, and T. P. Meehan Long-Term Mortality in Cerebrovascular Disease Stroke, March 1, 2003; 34(3): 699 - 704. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
I. L. Katzan, R. D. Cebul, S. H. Husak, N. V. Dawson, and D. W. Baker The effect of pneumonia on mortality among patients hospitalized for acute stroke Neurology, February 25, 2003; 60(4): 620 - 625. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J.C. Pressley, E.D. Louis, M.-X. Tang, L. Cote, P.D. Cohen, S. Glied, and R. Mayeux The impact of comorbid disease and injuries on resource use and expenditures in parkinsonism Neurology, January 14, 2003; 60(1): 87 - 93. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. F. Meschia Addressing the Heterogeneity of the Ischemic Stroke Phenotype in Human Genetics Research Stroke, December 1, 2002; 33(12): 2770 - 2774. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
D. L. Tirschwell and W.T. Longstreth Jr Validating Administrative Data in Stroke Research Stroke, October 1, 2002; 33(10): 2465 - 2470. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
T. S. Field, M. D. Hill, and M. D. Connor Weather, Chinook, and Stroke Occurrence * Editorial Comment Stroke, July 1, 2002; 33(7): 1751 - 1758. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
B. G. Vickrey, T. S. Rector, S. L. Wickstrom, P. M. Guzy, E. M. Sloss, P. B. Gorelick, S. Garber, D. F. McCaffrey, M. D. Dake, and R. A. Levin Occurrence of Secondary Ischemic Events Among Persons With Atherosclerotic Vascular Disease Stroke, April 1, 2002; 33(4): 901 - 906. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 K. Stavem and O.M. Ronning Survival of unselected stroke patients in a stroke unit compared with conventional care QJM, March 1, 2002; 95(3): 143 - 152. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 D. P. Scanlon, M. Chernew, H. E. Doty, and D. G. Smith Options for Assessing PPO Quality: Accreditation and Profiling as Accountability Strategies Med Care Res Rev, December 1, 2001; 58(4_suppl): 70 - 100. [Abstract] [PDF]
|
|
|
|
|
|
J. Fang, M. H. Alderman, and J. V. Tu Trend of Stroke Hospitalization, United States, 1988-1997 Editorial Comment Stroke, October 1, 2001; 32(10): 2221 - 2226. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 J. L. Bosch, M. T. Beinfeld, E. F. Halpern, J. S. Lester, and G. S. Gazelle Endovascular versus Open Surgical Elective Repair of Infrarenal Abdominal Aortic Aneurysm: Predictors of Patient Discharge Destination Radiology, September 1, 2001; 220(3): 576 - 580. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
L. A. Gillum and S. C. Johnston Characteristics of Academic Medical Centers and Ischemic Stroke Outcomes Stroke, September 1, 2001; 32(9): 2137 - 2142. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 M. D. Kluger, A. N. Sofair, C. J. Heye, J. I. Meek, R. K. Sodhi, and J. L. Hadler Retrospective Validation of a Surveillance System for Unexplained Illness and Death: New Haven County, Connecticut Am J Public Health, August 1, 2001; 91(8): 1214 - 1219. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. L. Bosch, J. S. Lester, P. M. McMahon, M. T. Beinfeld, E. F. Halpern, J. A. Kaufman, D. C. Brewster, and G. S. Gazelle Hospital Costs for Elective Endovascular and Surgical Repairs of Infrarenal Abdominal Aortic Aneurysms Radiology, August 1, 2001; 220(2): 492 - 497. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
C. A. Derby, K. L. Lapane, H. A. Feldman, and R. A. Carleton Possible Effect of DRGs on the Classification of Stroke : Implications for Epidemiological Surveillance Stroke, July 1, 2001; 32(7): 1487 - 1491. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
B. J. Quilliam, K. L. Lapane, and C. Leibson Clinical Correlates and Drug Treatment of Residents With Stroke in Long-Term Care Editorial Comment Stroke, June 1, 2001; 32(6): 1385 - 1393. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 W. M. Coplin, M. S. Cochran, S. R. Levine, and S. W. Crawford Stroke after bone marrow transplantation: Frequency, aetiology and outcome Brain, May 1, 2001; 124(5): 1043 - 1051. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
S. C. Johnston, L. H. Fung, L. A. Gillum, W. S. Smith, L. M. Brass, J. H. Lichtman, A. N. Brown, and D. Z. Wang Utilization of Intravenous Tissue-Type Plasminogen Activator for Ischemic Stroke at Academic Medical Centers : The Influence of Ethnicity Editorial Comment : It Is Time to Implement Stroke Practice Improvement Programs and Prevent the Racial Disparity in Stroke Care Stroke, May 1, 2001; 32(5): 1061 - 1068. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
J. Ray On the trail of necrotizing fasciitis in children Can. Med. Assoc. J., January 1, 2001; 164(2): 175 - 175. [Full Text] [PDF]
|
|
|
|
 |
|
 I. L. Katzan, A. J. Furlan, L. E. Lloyd, J. I. Frank, D. L. Harper, J. A. Hinchey, J. P. Hammel, A. Qu, and C. A. Sila Use of Tissue-Type Plasminogen Activator for Acute Ischemic Stroke: The Cleveland Area Experience JAMA, March 1, 2000; 283(9): 1151 - 1158. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
G. R. Williams, J. G. Jiang, D. B. Matchar, and G. P. Samsa Incidence and Occurrence of Total (First-Ever and Recurrent) Stroke Stroke, December 1, 1999; 30(12): 2523 - 2528. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
W. D. Rosamond, A. R. Folsom, L. E. Chambless, C.-H. Wang, P. G. McGovern, G. Howard, L. S. Copper, and E. Shahar Stroke Incidence and Survival Among Middle-Aged Adults : 9-Year Follow-Up of the Atherosclerosis Risk in Communities (ARIC) Cohort Stroke, April 1, 1999; 30(4): 736 - 743. [Abstract] [Full Text] [PDF]
|
|