2025 ICD-10-CM code I63.0
(Active) Effective Date: N/A Diseases of the circulatory system - Cerebral infarction due to thrombosis of precerebral arteries 9 Feed
Cerebral infarction due to thrombosis of precerebral arteries. This is a type of stroke caused by a blockage in one of the precerebral arteries, which supply blood to the brain.
Medical necessity for the diagnosis of cerebral infarction is established by the presence of characteristic neurological deficits and corresponding imaging findings confirming the infarction.Further investigations may be required to determine the underlying cause and guide treatment decisions.
Clinicians should document the specific artery affected, the cause of the thrombosis (if known), and any neurological deficits resulting from the infarction.It's also crucial to document the patient's NIH Stroke Scale (NIHSS) score (using additional code R29.7-), as this helps quantify the severity of the stroke.
In simple words: A stroke caused by a blood clot blocking one of the main arteries in the neck that supply blood to the brain.
A cerebral infarction occurs when blood flow to a part of the brain is blocked, resulting in damage to the brain tissue.In this specific case, the blockage is due to thrombosis (formation of a blood clot) within the precerebral arteries located in the neck. These arteries are responsible for delivering oxygen-rich blood to the brain, and their occlusion leads to an inadequate blood supply and subsequent infarction.
Example 1: A patient presents with sudden onset of right-sided weakness and difficulty speaking. Imaging reveals a thrombus in the left internal carotid artery, leading to a cerebral infarction. This would be coded as I63.0., A patient with a history of atrial fibrillation experiences a sudden loss of consciousness.A CT scan shows an infarction in the distribution of the middle cerebral artery, determined to be caused by a thromboembolism originating from the heart. This would be coded as I63.1 (Cerebral infarction due to embolism of precerebral arteries)., A patient presents with symptoms suggestive of a stroke, but imaging studies are inconclusive regarding the specific cause of the infarction. The documentation indicates a blockage in a precerebral artery but cannot definitively identify it as thrombosis or embolism.This would be coded as I63.2 (Cerebral infarction due to unspecified occlusion or stenosis of precerebral arteries).
Documentation should include details of the neurological examination, imaging findings (e.g., CT, MRI), and any other relevant diagnostic tests. Details regarding the affected vessel, laterality, and causation should be specified.If known, documentation of risk factors such as smoking, hypertension, and obesity is helpful.The NIHSS score should also be recorded.
** Consider using additional codes to specify the affected artery (e.g., internal carotid, vertebral), laterality (right or left), and any residual deficits.
- Specialties:Neurology, Neurosurgery, Internal Medicine, Cardiology, Emergency Medicine
- Place of Service:Inpatient Hospital, Emergency Room - Hospital, Skilled Nursing Facility