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2025 ICD-10-CM code I61.0

Nontraumatic intracerebral hemorrhage in the hemisphere, subcortical.

Adhere to the official ICD-10-CM coding guidelines published by the Centers for Medicare & Medicaid Services (CMS) and the WHO. Ensure accurate coding of any co-morbidities and contributing factors.

ICD-10 codes do not utilize modifiers. Modifiers are associated with CPT and HCPCS codes.

Medical necessity for diagnostic and treatment services is established by the clinical presentation, the severity of neurological symptoms, and the findings on brain imaging.Documentation should clearly support the diagnosis and the medical appropriateness of any interventions undertaken.

The clinical responsibility involves diagnosing the hemorrhage, determining its extent using imaging (CT, MRI), managing the patient's neurological status, and initiating appropriate treatment (e.g., medication, surgery).Ongoing monitoring and rehabilitation may also be necessary.

IMPORTANT:Use additional codes to specify contributing factors such as hypertension (I10-I15), alcohol abuse (F10.-), tobacco use (Z72.0), or other relevant conditions.Consider using codes from R29.7- for NIH Stroke Scale scores if available.

In simple words: This code means there's been bleeding inside the brain, not caused by an injury. The bleed is in the deeper part of the brain's hemisphere. This can happen because of high blood pressure or other health issues, and it can lead to brain damage.

This code signifies a spontaneous (nontraumatic) hemorrhage within the brain's hemisphere, specifically in the subcortical region (beneath the cortex).It indicates bleeding into the brain tissue, disrupting blood supply and potentially causing neurological deficits.This condition often stems from underlying factors such as hypertension.

Example 1: A 65-year-old male with a history of hypertension presents with sudden onset of severe headache, weakness on one side of the body, and slurred speech.CT scan reveals a large subcortical hemorrhage in the right hemisphere.I61.0 is used to code this diagnosis.Additional codes may be used for hypertension and stroke severity., A 50-year-old female with no significant past medical history presents with sudden onset of severe headache, followed by loss of consciousness.MRI shows a small subcortical hemorrhage in the left hemisphere.I61.0 is assigned, with additional codes for loss of consciousness and any secondary complications., A 70-year-old male with a history of anticoagulant use experiences a gradual onset of neurological decline over several days.Imaging reveals a small subcortical hemorrhage. I61.0 is coded. The use of anticoagulants might be coded separately to reflect a contributing factor.

Detailed patient history, neurological examination findings, imaging reports (CT or MRI demonstrating the hemorrhage's location and size), and any laboratory test results (e.g., complete blood count, coagulation studies) are required.Documentation of interventions (e.g., medications, surgical procedures) and the patient's response to treatment should also be meticulously recorded.

** This code should be used in conjunction with other codes as necessary to fully capture the patient's clinical picture.Consider coding the laterality (right or left hemisphere), the size of the hemorrhage, and any associated complications such as cerebral edema or hydrocephalus.Accurate documentation is crucial for proper reimbursement.

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