Coding of Stroke and Stroke Risk Factors Using

International Classification of Diseases, Revisions 9 and 10

Rae A. Kokotailo, BSc; Michael D. Hill, MD, MSc, FRCPC

Background and Purpose—Surveillance is necessary to understand and meet the future demands stroke will place on
health care. Administrative data are the most accessible data source for stroke surveillance in Canada. The International
Classification of Diseases, 10th revision (ICD-10) coding system has potential improvements over ICD-9 for stroke
classification. Our purpose was to compare hospital discharge abstract coding using ICD-9 and ICD-10 for stroke and
its risk factors.
Methods—We took advantage of a switch in coding systems from ICD-9 to ICD-10 to independently review stroke patient
charts. From time periods April 2000 to March 2001, 717 charts, and from April 2002 to March 2003, 249 charts were
randomly selected for review. Using a before-and-after time period design, the accuracy of hospital coding of stroke
(part I) and stroke risk factors (part II) using ICD-9 and ICD-10 was compared. We used careful definitions of stroke
and its types based on ICD-9 using the fourth and fifth digit modifier codes.
Results—Stroke coding was equally good with ICD-9 (90% [CI95 86 to 93] correct) and ICD-10 [92% (CI95 88 to 95
correct) with ICD-10. There were some differences in coding by stroke type, notably with transient ischemic attack, but
these differences were not statistically significant. Atrial fibrillation, coronary artery disease/ischemic heart disease,
diabetes mellitus, and hypertension were coded with high sensitivity (81% to 91%) and specificity (83% to 100%).
ICD-10 was as good as ICD-9 for stroke risk factor coding.
Conclusions—Passive surveillance using administrative data are a useful tool for identifying stroke and its risk factors
using both ICD-9 and ICD-10. (Stroke. 2005;36:1776-1781.)
Key Words: epidemiology 䡲 health services research 䡲 stroke 䡲 risk factors
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A n impending surge of new stroke cases and associated costs

are expected in Western countries from 2010 through 2030
as the 1945 to 1950 demographic reaches their seventh decade
and ages thereafter. Surveillance is necessary to determine the
future demands stroke will place on health care.1,2 This should
encompass stroke events and associated stroke risk factors. Such
data will permit informed decision making regarding healthcare
resource allocation to preventive and acute treatment programs.
Unlike cancer and some infectious diseases, there is little
active or passive surveillance of stroke and its risk factors.
One advantage of passive surveillance using administrative
data are that such data are readily available and are a
cost-effective resource compared with active surveillance.
This is particularly true in Canada, where a centralized
administrative structure to health care exists. Administrative
data have been used to quantify trends in stroke; however, it
has been criticized for lack of accuracy with low sensitivity
and specificity.3– 8 Furthermore, a particular disadvantage of
administrative data are the inability to ascertain stroke sever-
ity, which is the most important short- and long-term prog-
nostic variable. Nevertheless, stroke coding has been re-
viewed previously and found to be useful for high-level
comparisons, particularly when compared against other dis-
eases. We believe that a diagnostic accuracy of ⱖ85% is
adequate for assessing trends over time. However, stroke risk
factors have not been examined previously using administra-
tive data, and validation of existing coding would enrich the
utility of administrative data for surveillance of stroke.
Before fiscal year 2002/2003, medical centers in Alberta
used the International Classification of Diseases, 9th Revi-
sion (ICD-9), Clinical Modifications to code hospital dis-
charge abstracts. However, numerous studies have reported
inaccuracies using ICD-9.2,3,7,9,10 At the beginning of 2002,
the 10th revision replaced ICD-9 province-wide. Compared
with ICD-9, ICD-10 is qualitatively more intuitive and
specific for the diagnosis of ischemic stroke. We sought to
compare the proportion of correctly coded stroke patient
charts in academic and community hospitals (part I) and to
assess stroke risk factor coding (part II) using ICD-9 and
ICD-10 via a “before-after” study design.

Received March 12, 2005; final revision received April 10, 2005; accepted May 3, 2005.
From the Calgary Stroke Program, Departments of Clinical Neurosciences (M.D.H., R.A.K.), Medicine (M.D.H.), and Community Health Sciences
(M.D.H.), Faculty of Medicine, University of Calgary, Alberta, Canada.
Both authors contributed equally to this work.
Correspondence to Michael D. Hill, Associate Professor, Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary,
Foothills Hospital, Room 1242A, 1403 29th St NW, Calgary, Alberta, T2N 2T9, Canada. E-mail michael.hill@calgaryhealthregion.ca
© 2005 American Heart Association, Inc.
Stroke is available at http://www.strokeaha.org DOI: 10.1161/01.STR.0000174293.17959.a1

1776
 Kokotailo and Hill
TABLE 1. ICD Stroke Codes*
ICD-9
Stroke Type Code Definition
AIS 362.3 Retinal vascular occlusion
433.x1 Occlusion and stenosis of precerebral arteries
434.x1 Occlusion of cerebral arteries
436 Acute, but ill-defined cerebrovascular disease
ICH 431.x Intracerebral hemorrhage
SAH 430.x Subarachnoid hemorrhage
TIA 435.x Transient cerebral ischemia
*Excludes: 433.x0 (occlusion and stenosis of precerebral arteries without mention of cerebral infarction), 434.x0 (occlusion of cerebral arteries without mention
of cerebral infarction), 437.x (other and ill-defined cerebrovascular disease), 438.x (late effects of cerebrovascular disease), I65.x (occlusion and stenosis of precerebral
arteries not resulting in cerebral infarction), I66.x (occlusion and stenosis of cerebral arteries not resulting in cerebral infarction), I67.x (other cerebrovascular diseases),
I69.x (sequellae of cerebrovascular disease), and G45.4 (transient global amnesia) .
These criteria are investigator derived.
Methods
Data used for parts I and II of this study were retrieved from a
database of hospital discharge abstracts from the 3 adult acute care
sites: a university hospital (Foothills Medical Centre) and 2 commu-
nity hospitals (Peter Lougheed Centre and Rockyview General
Hospital) in the Calgary health region. These sites serve a population
of ⬇1.4 million people. Data from the Alberta Children’s Hospital
were not considered in this study. Each of the 3 acute care sites house
a computed tomography (CT) and MRI scanner. Data for this study
included patients admitted as inpatients as well as patients seen at the
emergency department and discharged without admission. It does not
include patients who were seen in an outpatient clinic, physician’s
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office, or those who did not present to medical attention. A single
health records technologist conducted coding of hospital discharge
abstracts at the university hospital. Before the study period, this
person trained with the Calgary Stroke Team, learning more about
stroke and its clinical diagnosis and management. Further, an
ongoing dialogue exists between the health records department and
the Calgary Stroke Team to resolve coding issues. At the 2
community hospitals, coding was not centralized to a single health
records technologist.
All patients with a discharge diagnosis (ICD-9 codes 430.x, 431.x,
433.x1, 434.x1, 435.x, 436, and 362.3) of stroke were acquired for
the 2000/2001 fiscal year (April to March); for the 2002/2003 fiscal
year, ICD-10 codes I60.x, I61.x, I63.x, I64.x, H34.1, and G45.x were
used to identify the patients. In ICD-9, the fourth and fifth digits
were used to exclude or include patients. In the intervening year,
coding switched from ICD-9 to ICD-10, and this time period
between data collection epochs allowed for learning on the new
ICD-10 system. All patients (n⫽2529) with a diagnosis of stroke in
the primary diagnostic position, implying that stroke was the most
responsible diagnosis for length of stay, comprised the sampling
frame. This approach has been shown to result in high specificity and
positive predictive value (PPV).3 A research assistant trained by a
stroke neurologist in definitions of stroke and its risk factors
performed the chart review. The neurologist resolved any ambigu-
ities in diagnosis. The investigators accessed the same patient chart
documents as health records technologists. If the chart contained
multiple admissions, only those documents from the admission under
review were used.
Part I
Major stroke types subarachnoid hemorrhage (SAH), intracerebral
hemorrhage (ICH), acute ischemic stroke (AIS), and transient
ischemic attack (TIA) were defined as described in Table 1. A
stratified random sample of charts was drawn for review, stratified
by major stroke type and by year. Sampling of AIS within the ICD-9
cohort was further oversampled compared with ICD-10 to allow for
Coding of Stroke Using ICD-9 and ICD-10 1777
ICD-10
Code Definition
H34.1 Central retina artery occlusion
I63.x Cerebral infarction
I64.x Stroke, not specified as hemorrhage or infarction
I61.x Intracerebral hemorrhage
I60.x Subarachnoid hemorrhage
G45.x Transient cerebral ischemic attacks and related syndromes
a better assessment of codes described as acute arterial occlusion
without infarct. The size of the sample varied between 10% and 65%
of the total available and was based on an expected precision of the
sensitivity and specificity defined by a 10% 95% CI width.
Patient charts were reviewed in detail. Physician history and
physical examination notes, physician progress notes, CT and MRI
imaging reports (if available), and discharge summaries were used to
ascertain the diagnosis most responsible for hospital length of stay
and to assign a code. The proportion of charts that were adjudicated
with available imaging reports (CT or MRI) was determined. Strokes
were coded as TIA if they resolved within 24 hours of onset, and if
imaging was performed, no detectable changes were evident. Using
our determination as the gold standard, the proportion correct of
hospital health technologist coding of AIS, SAH, ICH, and TIA
using ICD-9 and ICD-10 were then calculated and compared. For
practical reasons, chart reviewers were not blinded to how the charts
had been coded by the health records technologist.
Statistical comparisons were made using Fisher’s exact test, and
all proportions are reported using exact CIs. It was not possible to
assess the sensitivity and specificity for the diagnosis of stroke
because nonstroke diagnoses were underrepresented by design.
Instead, we report the PPV of coding by stroke type among patients
with stroke as well the Kappa statistic (␬) as a measure of the
agreement between coder and researcher. The PPVs were arbitrarily
categorized as “poor” (⬍70%), “good” (70% to 79%), “very good”
(80% to 89%), or “excellent” (ⱖ90%). ␬ was considered as having
substantial agreement between health technologist and researcher as
indicated by 0.61 to 0.80; almost perfect agreement: 0.81 to 1.00.3
Part II
A 10% random sample of charts, which included all available
diagnostic positions, was drawn from the sampling frame. The
sample size was estimated to provide, on average, a 10% 95% CI
width without adjustment to allow for multiple comparisons. Source
documents, namely physician history and physical examination
notes, physician progress notes, discharge summaries, nursing notes,
and laboratory, echocardiogram, and ECG reports were reviewed
systematically for atrial fibrillation, coronary artery disease/ischemic
heart disease, diabetes mellitus, history of cerebrovascular accident,
hypertension, hyperlipidemia, renal failure, and tobacco use. Codes
were assigned only to those risk factors that fulfilled the diagnostic
criteria as outlined in Table 2. Criteria were investigator derived, on
the basis of current medical guidelines. Using the gold standard, the
sensitivity, specificity, and percent correct of hospital health tech-
nologist coding of these stroke risk factors using ICD-9 and ICD-10
were calculated and compared.
 1778 Stroke August 2005

TABLE 2. Criteria and Indicators for Chart Review Diagnosis of Stroke Risk Factors
Risk Factor Criteria Indicators
Atrial fibrillation Paroxysmal or chronic AFIB History, ECG, holter monitoring
Coronary artery disease/ischemic heart disease Angina, myocardial infarction, or coronary atherosclerosis Angioplasty, stenting, CABG, ECHO, medication
Diabetes mellitus Type 1 diabetes or type 2 diabetes Fasting blood glucose History, medication, lab results
ⱖ7.0 mmol/L (126 mg/dL)
History of cerebrovascular disease Stroke, TIA, stroke(s), or TIA(s) History, imaging reports, medication
Hyperlipidemia Total cholesterol ⬎5.0 mmol/L (193 mg/dL), LDL History, medication
cholesterol ⬎3.0 mmol/L (116 mg/dL) lipoprotein analysis
done after a 9- to 12-hour fast
Hypertension Without diabetes: systolic BP ⱖ140 mm Hg; diastolic BP History, blood pressure readings in the
ⱖ90 mm Hg. With diabetes: systolic BP ⱖ135 mm Hg; nonacute phase, ⱖ1 week from admission,
diastolic BP ⱖ85 mm Hg average of ⱖ2 readings on ⱖ2 visits after
initial presentation, medication
Renal failure Serum creatinine ⱖ100 mmol/L (1.1 mg/dL) Hemodialysis, peritoneal dialysis, medication
Tobacco use Ex-smoker (daily for ⱖ1 year) or current smoker History
AFIB indicates atrial fibrillation; CABG, coronary artery bypass grafting; LDL, low-density lipoprotein; BP, blood pressure; ECHO, echocardiography.

Results similarly good with 92% (CI95, 88 to 95) of strokes correctly

Part I
A total of 461 charts from 2000/2001 (ICD-9) and 256
from 2002/2003 (ICD-10) were randomly selected for
review. The median age of patients was 71 (interquartile
range [IQR], 59 to 80), and 50.6% were female. The level
of agreement for stroke coding and the rate of correct
coding of stroke type by coding scheme and type of
hospital are listed in Table 3. The assessment of correct
coding was based on clinical data alone in 24.3% of charts
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coded; ␬⫽0.89 (CI95, 0.82 to 0.96). ICD-10 was not better
than ICD-9; P⫽0.865. TIA was correctly coded 97% of the
time (CI95 88 to 99) compared with 70% (CI95 56 to 82) with
ICD-9; P⫽0.266. The range of coding errors was largely as
expected, with stroke types confused with one another,
notably TIA for AIS and ICH for SAH (Table 4). We found
that the use of the modifier codes (fourth and fifth digit) in the
ICD-9 excluded 95 cases of carotid endarterectomy that had
not had an index stroke on the noted admission. This

(no neurovascular imaging was done, or no imaging
reports were available for review) and on clinical data and
neurovascular imaging reports in 75.6% of charts.
On the whole, ICD-9 coding was excellent with 90% (CI95,
86 to 92) correct; ␬⫽0.86 (CI95, 0.81 to 0.91). ICD-10 was
substantially increased the accuracy of ICD-9 coding for
ischemic stroke when including code 433 in the stroke
definition.
At the hospital level, within each coding system, coding
was nonsignificantly better using ICD-10 at 95% (CI95, 91 to

TABLE 3. PPV and Agreement of Stroke Type Coding by ICD Coding and Hospital Site
ICD-9 ICD-10

On Hospital Identified by On Hospital Identified by

Discharge Abstract Chart Review % Correct ␬ Discharge Abstract Chart Review % Correct ␬
Stroke Type (no.) (no.) (CI95) (CI95) (no.) (no.) (CI95) (CI95)
University hospital site 0.87 (0.81–0.93) 0.93 (0.85–1.00)
AIS 100 117 86 (78–91) 52 57 91 (81–97)
ICH 61 62 98 (91–99.9) 52 52 100 (93)*
SAH 48 49 98 (89–99) 30 33 91 (76–98)
TIA 28 39 72 (55–85) 52 53 98 (90–99)
Community hospital site 0.82 (0.72–0.93) 0.71 (0.55–0.88)
AIS 34 40 85 (70–94) 19 27 70 (50–86)
ICH 15 16 94 (70–99) 15 16 94 (70–99)
SAH 3 3 100 (29)* 2 2 100 (16)*
TIA 9 14 64 (35–87) 8 9 89 (52–99)
All sites 0.86 (0.81–0.91) 0.89 (0.82–0.96)
AIS 133 157 85 (78–90) 75 88 85 (76–92)
ICH 76 78 97 (91–99.7) 67 68 98 (92–99)
SAH 51 52 98 (90–99) 32 35 91 (77–98)
TIA 37 53 70 (56–82) 60 62 97 (88–99)
*97.5% 1-sided lower CI.
 Kokotailo and Hill Coding of Stroke Using ICD-9 and ICD-10 1779

TABLE 4. Coding Errors by Stroke Type and ICD Coding

ICD-9 ICD-10

No. Coding Based on Chart Review No. Coding Based on Chart Review
Stroke Type
AIS 18 (123)* 16-TIA 4-weakness unspecified 4-other 2-admitted to rehabilitation nonacutely 2 2-TIA
1-SAH 1-missing chart (95-admitted for elective carotid endarterectomy)*
ICH 0 12 8-AIS 3-SAH 1-missing chart
SAH 3 2-ICH 1-admitted to rehabilitation nonacutely 1 1-ICH
TIA 1 1-AIS 6 5-AIS 1-admitted to rehabilitation non-acutely
*Carotid endarterectomy patients were identified correctly when using the fourth and fifth digits of the ICD-9 coding system. They were coded as vascular occlusion
without infarct. They are included here to emphasize what the specific use of the fourth and fifth digits are in our sample.

98) accuracy at the university site compared with 80% (CI95, Part II
68 to 90) accuracy at the community sites (P⫽0.503). A total of 137 charts from 2000/2001 (ICD-9) and 112 from
Differences were less marked with ICD-9 (90% versus 89% 2002/2003 (ICD-10) were randomly selected for review. The
accuracy; P⫽0.883). median age of patients was 73 (IQR, 65 to 81), and 49% were

TABLE 5. Sensitivity, Specificity, PPV, and Agreement of Stroke Risk Factors by ICD Coding and Hospital Site
ICD-9 ICD-10

Sensitivity Specificity % Correct ␬ Sensitivity Specificity % Correct ␬

Stroke Risk Factor (CI95) (CI95) (CI95) (CI95) (CI95) (CI95) (CI95) (CI95)
University hospital site
AFIB 73 (39–94) 99 (92–99.9) 95 (87–99) 0.77 (0.66–0.89) 100 (63)* 97 (90–99) 98 (91–99) 0.88 (0.79–0.96)
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CAD/IHD 89 (71–98) 94 (83–99) 92 (84–97) 0.83 (0.76–0.91) 86 (65–97) 97 (88–99) 94 (86–98) 0.84 (0.84–0.92)
DM 94 (69–99)3 98 (91–99) 98 (91–99) 0.92 (0.87–0.98) 87 (66–97) 100 (94)* 96 (89–99) 0.91 (0.85–0.97)
History of CVA 44 (25–65) 100 (93)* 81 (70–89) 0.51 (0.41–0.61) 48 (29–68) 93 (82–98) 78 (67–87) 0.45 (0.35–0.56)
Hyperlipidemia 70 (44–89) 98 (91–99) 92 (84–97) 0.75 (0.67–0.84) 67 (51–81) 100 (91)* 83 (73–90) 0.67 (0.57–0.77)
Hypertension 84 (71–94) 88 (71–97) 86 (76–93) 0.72 (0.63–0.81) 95 (85–99) 88 (67–97) 93 (84–97) 0.82 (0.75–0.90)
RF 50 (6–93) 99 (94–99.9) 96 (89–99) 0.55 (0.34–0.76) 66 (22–96) 100 (95)* 98 (91–99) 0.79 (0.63–0.95)
Tobacco use 0 (9)† 98 (87–99) 52 (40–63) -0.03 (⫺0.09–0.05) 25 (13–40) 100 (98)* 60 (48–71) 0.24 (0.16–0.31)
Community hospital sites
AFIB 90 (55–99) 100 (92)* 98 (90–99) 0.94 (0.87–1.0) 63 (24–91) 100 (83)* 90 (72–98) 0.71 (0.58–0.84)
CAD/IHD 77 (54–92) 83 (67–94) 81 (68–90) 0.60 (0.50–0.71) 90 (55–99) 100 (82)* 97 (82–99) 0.92 (0.87–0.97)
DM 90 (66–99) 100 (90)* 97 (93)* 0.92 (0.86–0.98) 100 (69)* 95 (73–99) 97 (82–99) 0.93 (0.87–0.98)
History of CVA 13 (3–30) 100 (87)* 53 (39–67) 0.12 (0.02–0.23) 10 (0–44) 100 (82)* 69 (49–85) 0.13 (0.02–0.23)
Hyperlipidemia 36 (11–69) 100 (78)* 88 (76–95) 0.48 (0.36–0.60) 40 (12–74) 100 (82)* 79 (60–92) 0.47 (0.35–0.59)
Hypertension 79 (63–90) 100 (78) 85 (72–93) 0.66 (0.56–0.76) 74 (51–90) 67 (22–96) 72 (52–87) 0.33 (0.21–0.45)
RF 25 (3–65) 98 (89–99) 88 (77–95) 0.31 (0.09–0.53) 50 (1–99) 96 (81–99) 93 (77–99) 0.46 (0.24–0.68)
Tobacco use 17 (4–37) 100 (89)* 66 (51–77) 0.19 (0.11–0.27) 43 (9–81) 100 (84)* 86 (68–96) 0.53 (0.46–0.60)
All sites
AFIB 81 (58–96) 99 (95–99.9) 96 (91–99) 0.85 (0.76–0.95) 98 (92–99) 96 (89–99) 98 (92–99) 0.81 (0.71–0.92)
CAD/IHD 84 (70–93) 90 (81–95) 88 (81–93) 0.73 (0.64–0.82) 98 (4–19) 95 (88–98) 98 (4–19) 0.87 (0.80–0.92)
DM 91 (76–98) 99 (94–99.9) 97 (92–99) 0.92 (0.87–0.98) 99 (93–99.9) 97 (91–99) 99 (93–99.9) 0.91 (0.86–0.97)
History of CVA 28 (16–41) 100 (95)* 69 (61–77) 0.31 (0.20–0.41) 95 (87–99) 76 (67–83) 95 (87–99) 0.37 (0.27–0.48)
Hyperlipidemia 57 (37–76) 99 (95–99.9) 91 (84–95) 0.66 (0.56–0.76) 100 (94)* 82 (74–89) 100 (94)* 0.63 (0.53–0.74)
Hypertension 82 (72–89) 92 (80–98) 85 (78–91) 0.70 (0.60–0.79) 83 (65–94) 88 (79–93) 83 (65–94) 0.69 (0.60–0.79)
RF 33 (9–65) 98 (94–99) 93 (87–96) 0.41 (0.19–0.63) 99 (94–99.9) 96 (91–99) 99 (94–99.9) 0.70 (0.51–0.88)
Tobacco use 7 (1–16) 99 (92–99.9) 58 (48–66) 0.06 (⫺0.02–0.13) 100 (94)* 67 (57–76) 100 (94)* 0.29 (0.22–0.37)
AFIB indicates atrial fibrillation; CAD/IHD, coronary artery disease/ischemic heart disease; DM, diabetes mellitus; CVA, cerebrovascular accident; RF, renal failure.
*97.5% 1-sided lower CI; †97.5% 1-sided upper CI.
 1780 Stroke August 2005
female. Table 5 summarizes the sensitivity, specificity, and
PPV of stroke risk factors according to ICD system and
hospital site. Overall, coding of all risk factors was found to
be similar between ICD-9 and ICD-10. Global sensitivity was
lower, with ICD-10 at 58% (CI95, 52 to 63) compared with
67% (CI95, 61 to 72); P⫽0.234. Overall specificity was equal
at 97% (CI95, 96 to 98) compared with 97% (CI95, 96 to 99);
P⫽1.000. Overall accuracy was similar at 84% (CI95, 82 to
87) compared with 87% (CI95, 84 to 89); P⫽0.691. Charac-
teristic of both schemes, atrial fibrillation, coronary artery
disease/ischemic heart disease, diabetes mellitus, and hyper-
tension coding was very good to excellent, showing a high
degree of sensitivity and specificity. Conversely, coding of a
history of cerebrovascular accident, hyperlipidemia, renal
failure, and tobacco use ranged from poor to excellent, having
quite low sensitivity but high specificity. The sensitivity
improved only slightly for these risk factors with the switch
to ICD-10. These trends were observed at the hospital level.
No differences were observed between the university and
community hospital sites.
Discussion
Our data suggest that the administrative diagnoses of stroke
and its risk factors are quite good and that no quantitative
improvements have been realized with the switch to the
ICD-10 system. Two caveats associated with using such data
to make reliable conclusions are worth review. First, by
definition, they apply only to hospital-based care. Therefore,
data from those individuals who do not seek medical attention
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or who are only seen in outpatient clinic or offices are not
captured.2,11 For stroke, this results in a slight bias to more
severe strokes because patients with only mild symptoms
may not seek medical attention. This has been well demon-
strated in Texas, where active and passive surveillance
conducted concurrently showed that some cases were identi-
fied by active surveillance that were missed completely by
the passive surveillance system. Interestingly, the converse
was also true in that cases identified by passive surveillance
were missed by the active surveillance system.11
Second, administrative data depend on clerical staff inter-
preting the medical record and applying appropriate codes.
Coding of stroke and its risk factors, like all hospital
discharge abstract coding, depends on the quality of the data
in the chart and the expertise of the coder. Charting is highly
variable, and validation studies done in one setting may not
apply across jurisdictions. We have shown previously that
there exists wide variation in stroke coding using ICD-9 in
rural compared with urban hospitals.12 Rural hospitals tended
to code stroke using more general codes, whereas urban
coding was more specific. The centralization of stroke ser-
vices and the establishment of an inpatient stroke unit,13 as
well as the training of a health records technologist at
Foothills Medical Centre, may be 2 unique factors contribut-
ing to the results of our study.
Our results concur with those of Goldstein,8 who showed
that a substantial minority of patients (15% to 20%) coded as
having a stroke never had one. We used modifier codes
(fourth and fifth digit in the ICD-9 system) to exclude
patients who were admitted for carotid endarterectomy but
had not had an index stroke on that admission. In the ICD-9
system for coding AIS, there are several codes that are
described as acute arterial occlusion without infarct (433.00,
433.10, 433.20, 433.30, 434.10, and 434.90). In our study, all
95 cases of elective carotid endarterectomy were coded as
acute arterial occlusion without infarct. As suggested by
Goldstein, these codes have particularly low accuracy for the
diagnosis of true stroke. This problem does not occur with
ICD-10.
The identification of stroke risk factors is more variable.
Atrial fibrillation, coronary artery disease/ischemic heart
disease, diabetes mellitus, and hypertension are identified
with a high degree of confidence, whereas history of cere-
brovascular disease, hyperlipidemia, renal failure, and to-
bacco use are identified to a lesser degree. The poor coding of
the latter 4 risk factors may be attributable to poor charting by
physicians and nursing staff, a lack of perceived importance
by health technologist coders, or a lack of time to “code
everything.” Education and understanding may help to im-
prove this situation. The emergence of the electronic health
record may allow automated and better coding of such risk
factors within administrative databases. The ICD-10 system
itself might benefit from the inclusion of more specific
diagnostic codes for these comorbidities to improve their true
diagnosis. However, the ability to reliably identify stroke risk
factors among stroke patients using administrative data is an
important addition to use of such data in health services
research.
Our study has notable limitations. We were unable to blind
the chart reviewer to either the health records technologist
coding or to which coding system was used because of
practical limitations. Further, our system includes an active
dialogue between the health records coder and the Calgary
Stroke Team, meaning that our results may not be as
generalizable to other jurisdictions. Our sampling frame was
limited to those patients with stroke in the primary diagnostic
position. Although this improves the specificity of diagnosis,
it may limit sensitivity, implying that we may not have
included patients with stroke in other diagnostic positions.
Overall, our data provide evidence that stroke coding with
ICD-10 is similar to ICD-9. The greater clarity in definitions
in the ICD-10 system may provide a qualitative advantage.
Acknowledgments
M.D.H. was supported by the Heart and Stroke Foundation of
Alberta/NWT/Nunavut and the Canadian Institutes for Health Re-
search. We would like to thank Chris Makar for her ongoing
commitment to stroke coding.
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