NIHSS score 4

This code indicates a National Institutes of Health Stroke Scale (NIHSS) score of 4. The NIHSS is a standardized, systematic assessment tool used to quantify neurological deficits in patients who have experienced an acute stroke, evaluating areas such as consciousness, motor function, sensation, and language. A score of 4 generally suggests a mild to moderate stroke severity.

Use this code when documentation explicitly states an NIHSS score of 4 for a patient with an acute cerebrovascular event. This score is typically assessed by emergency medical personnel, neurologists, or other healthcare providers in the acute phase of stroke management. Supporting documentation includes physician notes, neurological assessments, and emergency department records.

• Always ensure the NIHSS score is clearly documented by the treating physician or assessing clinician.
• Do not assign this code without a specific, documented NIHSS score; avoid inferring the score from general descriptions of stroke severity.
• This code should be sequenced after the primary diagnosis code for the acute stroke (e.g., I63.x for ischemic stroke).