2025 ICD-10-CM code I63.9
(Active) Effective Date: N/A Diseases of the circulatory system - Cerebrovascular diseases 9 Feed
Cerebral infarction, unspecified.A stroke caused by a blockage of blood vessels in the brain, leading to damage of brain tissue.
Medical necessity for the diagnosis and treatment of cerebral infarction is established by the presence of neurological deficits and confirmation of the infarction through appropriate imaging studies. The medical record must clearly document the symptoms, diagnostic findings, and treatment plan.
Physicians diagnosing and treating cerebrovascular diseases, such as neurologists, emergency medicine physicians, and internists, are responsible for accurately documenting and coding cerebral infarction. This involves identifying the underlying cause, assessing the extent of neurological deficits, and providing appropriate medical care.
In simple words: A stroke happens when the blood supply to part of your brain is cut off, damaging brain tissue. This is called a cerebral infarction.
Cerebral infarction occurs when a blood vessel supplying the brain becomes blocked, resulting in damage to the brain tissue. This is commonly referred to as a stroke.Various blood vessels in the neck and brain supply blood to the brain. In this specific scenario, insufficient blood flow through certain cerebral blood vessels leads to inadequate perfusion of the brain tissue. Several factors can cause this blockage, including narrowing of the blood vessel by deposits, inflammation, or changes in the vessel wall, all of which restrict blood flow.
Example 1: A patient presents to the emergency room with sudden onset of right-sided weakness and difficulty speaking. Imaging reveals a blockage in a cerebral artery, confirming a diagnosis of cerebral infarction.The physician documents the findings and assigns code I63.9 due to the unspecified location of the infarction., A patient with a history of atrial fibrillation experiences a sudden loss of consciousness. Upon regaining consciousness, the patient exhibits signs of neurological impairment.Diagnostic tests confirm a cerebral infarction, but the specific affected vessel is not identified.Code I63.9 is used., A patient with hypertension and diabetes develops gradual neurological symptoms over several days, including dizziness and confusion. Imaging reveals multiple small infarcts throughout the brain.In the absence of information about the specific affected vessel, I63.9 is assigned.
Documentation should include detailed neurological findings, imaging results (CT, MRI), and any other relevant diagnostic tests.Information about the onset of symptoms, risk factors (e.g., hypertension, diabetes, atrial fibrillation), and any associated conditions should also be recorded.If a specific vessel is identified later, the code should be updated to reflect the more precise diagnosis.
** Excludes2: transient cerebral ischemic attacks and related syndromes (G45.-)
- Specialties:Neurology, Emergency Medicine, Internal Medicine, Cardiology
- Place of Service:Inpatient Hospital, Emergency Room - Hospital, Office