Transient Ischemic Attack Documentation Guide
Brief episode of neurological dysfunction from focal cerebral ischemia without infarction.
ICD-10 Codes: G45.0, G45.1, G45.2, G45.8, G45.9
Common Symptoms
- Transient focal weakness
- Speech difficulty
- Visual disturbance
- Ataxia
- Sensory changes
Key Documentation Elements
- ABCD2 score components and total
- Neurological deficit description and time to resolution
- Vascular imaging (CTA, MRA, carotid ultrasound) results
- Cardiac evaluation (ECG, echocardiogram, telemetry)
- Secondary prevention plan (antiplatelets, statins, risk factor management)
Documentation Challenges
- Documenting ABCD2 score for stroke risk stratification
- Recording time course and resolution of symptoms
- Capturing vascular imaging and cardiac evaluation results
- Distinguishing TIA from stroke and TIA mimics
Billing Considerations
- Territory-specific TIA coding (G45.0 vertebrobasilar, G45.1 carotid)
- DWI-negative MRI requirement to distinguish from stroke
- Observation vs admission documentation for ABCD2-based disposition
Frequently Asked Questions
How are different TIA types coded?
TIA codes are territory-specific: G45.0 (vertebrobasilar), G45.1 (carotid/hemispheric), G45.2 (multiple/bilateral), G45.9 (unspecified). Scribeable maps your documented deficits to the appropriate vascular territory code.
How does Scribeable assist with TIA evaluation documentation?
Scribeable captures ABCD2 components, deficit timeline, imaging results, and secondary prevention decisions from your encounter, creating structured documentation that supports time-sensitive TIA workup.