2025 ICD-10-CM code I69.3
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Cerebrovascular diseases - Sequelae of cerebrovascular disease Diseases of the circulatory system (I00-I99) Feed
Sequelae of cerebral infarction; long-term effects after a stroke.
Modifiers may be applicable depending on the specific circumstances of service and the payer's guidelines.
Medical necessity for ongoing care for sequelae of cerebral infarction is established based on the presence of persistent impairments that interfere with the patient's ability to perform activities of daily living and require ongoing medical management and/or rehabilitation services.The necessity is documented through the clinical findings and functional assessments.
The clinical responsibility for patients with sequelae of cerebral infarction involves ongoing neurological assessment, rehabilitation, and management of associated complications. This may involve neurologists, physiatrists, speech-language pathologists, occupational therapists, and other healthcare professionals.
In simple words: This code is used when someone has long-term problems after having a stroke.These problems can include weakness, trouble speaking, memory problems, or difficulty swallowing. The specific problems will depend on which part of the brain was affected by the stroke.
This code signifies the lasting consequences following a cerebral infarction (stroke).It encompasses a wide range of neurological, cognitive, and physical impairments that may persist after the acute phase of the stroke has resolved. These sequelae can include but are not limited to motor deficits (weakness, paralysis), sensory disturbances, cognitive impairments (memory loss, aphasia, apraxia), speech and language disorders, and swallowing difficulties.The specific manifestations vary widely depending on the location and extent of the brain damage.
Example 1: A 65-year-old patient experienced a left-hemisphere stroke six months ago.They now present with right-sided hemiparesis, aphasia, and dysphagia.Code I69.3 would be used, along with additional codes to specify the aphasia (e.g., I69.320) and dysphagia (e.g., I69.391)., A 72-year-old patient had a stroke two years ago, resulting in persistent right-sided weakness and cognitive impairment, including memory loss and difficulty with problem-solving. Code I69.3 would be used, potentially with I69.31 to specify the cognitive deficits., An 80-year-old patient with a history of stroke exhibits persistent gait ataxia and dysarthria.Code I69.3 is used, with potential addition of codes for ataxia and dysarthria, depending on the clinical assessment.Additional codes may be used to identify other impairments such as vision problems, or cognitive deficits.
Detailed history of the stroke, including date of onset, location, and severity.Comprehensive neurological examination documenting residual deficits (motor, sensory, cognitive, speech, swallowing).Results of any relevant imaging studies (CT scan, MRI).Documentation of any ongoing therapy or rehabilitation interventions.Progress notes reflecting the patient's functional status and ongoing needs.
** This code should only be used for long-term consequences of a stroke.Transient ischemic attacks (TIAs) are excluded.
- Payment Status: Active
- Specialties:Neurology, Physical Medicine and Rehabilitation, Speech-Language Pathology
- Place of Service:Inpatient Hospital, Outpatient Hospital, Skilled Nursing Facility, Rehabilitation Facility, Office