2025 ICD-10-CM code R29.7
National Institutes of Health Stroke Scale (NIHSS) score. Code first the type of cerebral infarction (I63.-).
The NIHSS is a standardized assessment tool used to objectively quantify neurological deficits in stroke patients. It aids in establishing stroke severity, treatment planning, and monitoring patient progress. Therefore, the documentation of the NIHSS score is medically necessary for patients diagnosed with stroke.
Clinicians, including physicians, physician assistants, and nurse practitioners, are responsible for administering the NIHSS and documenting the score.
In simple words: This code represents a score from the National Institutes of Health Stroke Scale (NIHSS), which helps healthcare professionals assess the severity of a stroke.It should be used alongside a code that indicates the specific type of stroke.
National Institutes of Health Stroke Scale (NIHSS) score. This code should be used in conjunction with a code for the type of cerebral infarction (I63.-).
Example 1: A patient presents to the emergency room with symptoms of stroke. The physician performs the NIHSS assessment and determines the score to be 15. The coder would assign the codes I63.9 (Cerebral infarction, unspecified) and R29.715 (NIHSS score 15)., A patient with a history of stroke is admitted for rehabilitation. The NIHSS score is documented as 7 upon admission. The appropriate codes would be the appropriate code from category I69.- (Sequelae of cerebrovascular disease) and R29.707 (NIHSS score 7)., A patient arrives at the hospital with suspected transient ischemic attack (TIA). After evaluation, the NIHSS score is recorded as 2. While TIA and stroke share similar symptoms, TIA symptoms often resolve on their own. After further testing a stroke is confirmed. The coder would report the confirmed diagnosis of stroke and R29.702 (NIHSS score 2).
The NIHSS score must be documented by the clinician performing the assessment. The documentation should clearly state the total NIHSS score. Additional documentation supporting the individual components of the NIHSS is also recommended.
** The NIHSS score helps healthcare professionals to determine stroke severity, which can guide treatment decisions and predict outcomes.
- Specialties:Neurology, Emergency Medicine, Internal Medicine, Physical Medicine and Rehabilitation
- Place of Service:Inpatient Hospital, Emergency Room - Hospital, Skilled Nursing Facility, Rehabilitation Facility, Outpatient Hospital, Office