2025 ICD-10-CM code I63.3
(Active) Effective Date: N/A Diseases of the circulatory system - Cerebrovascular Diseases 9 Feed
Cerebral infarction due to thrombosis of cerebral arteries. This condition involves the blockage of blood flow in the brain due to a blood clot (thrombus) forming within a cerebral artery.
Medical necessity for treatment is established by the presence of a cerebral infarction confirmed by imaging and attributed to a thrombotic occlusion. The specific treatments administered should be documented and justified based on the patient's clinical condition and established guidelines.
Diagnosis and management of cerebral infarction due to thrombosis of cerebral arteries typically falls under the purview of neurologists, internists, hospitalists, and emergency medicine physicians.They are responsible for confirming the diagnosis, assessing the severity of the stroke, and initiating treatment.Treatment focuses on restoring blood flow to the affected area of the brain, managing complications, and preventing further strokes.
In simple words: A stroke caused by a blood clot forming in an artery in the brain.
Cerebral infarction occurs when a blood clot blocks a cerebral artery, leading to an interruption of blood supply to a part of the brain.This blockage causes tissue death (infarction) in the affected area. In this specific case, the blockage is caused by a thrombus, which is a blood clot that forms within the vessel itself, as opposed to an embolus, which is a clot that travels from elsewhere in the body.
Example 1: A 65-year-old patient presents with sudden onset right-sided weakness and difficulty speaking. Imaging reveals a cerebral infarction in the left middle cerebral artery territory, and further investigation confirms the presence of a thrombus as the cause of the blockage., A 78-year-old patient with a history of atrial fibrillation experiences a sudden loss of consciousness.Imaging reveals multiple small cerebral infarctions due to thrombotic occlusions of smaller cerebral arteries., A 50-year-old patient with a known hypercoagulable state develops progressive neurological symptoms over several hours. Imaging shows a cerebral infarction in the right anterior cerebral artery territory, caused by a thrombus.
Documentation should include details of the patient's presenting symptoms (e.g., neurological deficits, time of onset), imaging findings (e.g., location and size of infarction), diagnostic tests performed (e.g., CT scan, MRI), and any other relevant medical history (e.g., risk factors for stroke). Information regarding the NIH Stroke Scale (NIHSS) score should also be included.If known, the affected vessel and laterality should also be documented.
** Consider using additional codes to specify the presence of conditions like alcohol abuse, tobacco dependence, hypertension, or occupational exposure to tobacco smoke, if applicable.
- Payment Status: Active
- Specialties:Neurology, Internal Medicine, Emergency Medicine, Hospital Medicine
- Place of Service:Inpatient Hospital, Emergency Room - Hospital, Skilled Nursing Facility