NIHSS score 16

This code indicates a National Institutes of Health Stroke Scale (NIHSS) score of 16, reflecting a moderate to severe neurological deficit in a patient who has experienced a stroke. The NIHSS is a standardized tool used to quantify the severity of stroke-related neurological impairment, assessing various functions such as consciousness, motor strength, sensation, and language.

Use this code when documentation explicitly states an NIHSS score of 16 following an acute cerebrovascular event. This score is typically determined by a clinician during the initial assessment of a stroke patient. Supporting documentation includes physician notes, neurological assessments, and emergency department records.

• Always ensure the specific NIHSS score (16) is clearly documented; do not infer from descriptive terms like "moderate stroke."
• This code should be sequenced as a secondary diagnosis, following the primary code for the acute stroke (e.g., I63.x).
• Do not use this code if the NIHSS score is not precisely 16; select the appropriate code for the documented score.