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2025 ICD-10-CM code I65.1

Occlusion and stenosis of the basilar artery.

Follow the official ICD-10-CM coding guidelines published by the Centers for Medicare & Medicaid Services (CMS).Ensure consistent use of the most specific code available based on the clinical documentation.

Modifiers are not applicable to ICD-10-CM codes. Modifiers are used with procedural codes (CPT, HCPCS).

Medical necessity for diagnostic procedures or treatment will depend on the patient's clinical presentation and the severity of the condition.Document the medical necessity for all procedures performed.Justify the diagnosis based on clinical findings and imaging studies. Compliance with payer-specific medical necessity criteria is essential for reimbursement.

Diagnosis and management of the condition typically fall under the responsibility of neurologists, vascular surgeons, or other specialists depending on the severity and presentation.

IMPORTANT:Consider using additional codes to specify associated conditions such as alcohol abuse, tobacco use or dependence, hypertension, or exposure to environmental tobacco smoke.Code I63 should be considered if there is a cerebral infarction.

In simple words: This code indicates a blockage or narrowing of the basilar artery, a major blood vessel in the brain.This can reduce blood flow to parts of the brain, potentially causing neurological problems.

This ICD-10-CM code signifies occlusion (complete blockage) and stenosis (narrowing) of the basilar artery, a major artery supplying blood to the brainstem and cerebellum.The condition can lead to various neurological deficits depending on the extent and location of the blockage.It is crucial to specify the affected vessel and laterality (right or left side) in documentation.

Example 1: A 70-year-old patient presents with sudden onset of dizziness, vertigo, and diplopia.Imaging reveals occlusion of the basilar artery.The patient is diagnosed with I65.1 and admitted for further evaluation and treatment., A 65-year-old patient with a history of hypertension and smoking experiences progressive neurological decline including ataxia and dysarthria.Angiography confirms significant basilar artery stenosis. The patient undergoes endovascular intervention and is coded with I65.1., A 50-year-old patient presents with sudden, severe headache and loss of consciousness. CT scan demonstrates a basilar artery occlusion causing acute brainstem infarct.The diagnosis of I65.1 is supported by the imaging findings and the patient undergoes thrombolytic therapy.

Detailed clinical history, neurological examination findings, and imaging results (such as CT angiography or MR angiography) are crucial for accurate coding.Specify the affected vessel and laterality.Note any associated conditions, such as hypertension, heart disease, or previous strokes.

** This code is for occlusion and stenosis of the basilar artery itself.If the occlusion or stenosis leads to a cerebral infarction (stroke), separate codes for the stroke would be required, in addition to I65.1.Always cross-reference with the complete clinical picture to ensure accurate coding.Always refer to the most up-to-date ICD-10-CM coding guidelines.

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