2025 ICD-10-CM code I63.4
Cerebral infarction caused by an embolism blocking a cerebral artery, leading to restricted blood flow and brain tissue damage.
Medical necessity for services related to I63.4 is established by the acute presentation of neurological deficits consistent with cerebral infarction, requiring prompt evaluation and management to minimize brain damage and long-term disability. The medical record must clearly document the signs, symptoms, and diagnostic findings supporting the diagnosis and the rationale for treatment interventions.
Physicians involved in diagnosing and managing cerebral infarction due to embolism, such as neurologists, emergency medicine physicians, and internists, are responsible for accurate documentation, appropriate diagnostic testing (e.g., imaging studies, EKG), and timely intervention including medical management (e.g., thrombolytics) or referral to specialized care (e.g., stroke unit, neurosurgery) based on the patient's condition.
In simple words: A stroke caused by a blood clot that traveled to the brain and blocked an artery, resulting in brain damage.
A cerebral infarction occurs when an embolus (a blood clot or other foreign material) travels through the bloodstream and lodges in a cerebral artery, obstructing blood flow to a specific part of the brain. This blockage deprives the brain tissue of oxygen and nutrients, resulting in tissue damage and potentially neurological deficits, often recognized as a stroke.Various risk factors, including smoking, obesity, and high blood pressure, can contribute to the development of emboli and subsequent cerebral infarction.
Example 1: A 65-year-old patient with atrial fibrillation presents with sudden onset right-sided weakness and aphasia. Imaging reveals a cerebral infarction in the left middle cerebral artery territory, consistent with an embolic stroke., A patient with a history of carotid artery stenosis experiences sudden onset of visual disturbances and dizziness. Diagnostic studies confirm a cerebral infarction in the posterior cerebral artery distribution due to an embolus from the diseased carotid artery., Following a recent heart valve replacement, a patient develops acute neurological symptoms including hemiparesis.Imaging confirms a cerebral infarction caused by an embolus originating from the artificial heart valve.
Documentation for I63.4 should include detailed neurological examination findings, imaging results (CT, MRI) confirming the location and extent of the infarction, and evidence supporting the embolic etiology, such as cardiac arrhythmias, valvular disease, or other sources of emboli.Documentation of any associated deficits, such as aphasia, hemiparesis, or sensory loss, is also crucial.
** Consider using additional codes to document the NIH Stroke Scale (NIHSS) score (R29.7-) if available, as it helps quantify stroke severity and track progress.
- Specialties:Neurology, Emergency Medicine, Internal Medicine, Cardiology, Cardiovascular Surgery
- Place of Service:Inpatient Hospital, Emergency Room - Hospital, Skilled Nursing Facility