ICD-10 Coding for Acute Ischemic Left Middle Cerebral Artery Stroke(I63.412)
Complete ICD-10-CM coding and documentation guide for Acute Ischemic Left Middle Cerebral Artery Stroke. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Acute Ischemic Left Middle Cerebral Artery Stroke
I63.40-I63.49Primary Range
Cerebral infarction due to embolism
This range includes codes for cerebral infarctions due to embolism, specifically detailing laterality and artery involvement.
Sequelae of cerebral infarction
This range is used for coding residual effects after the acute phase of a cerebral infarction.
Key Information: ICD-10 code for left MCA stroke
Essential facts and insights about Acute Ischemic Left Middle Cerebral Artery Stroke
Primary ICD-10-CM Code for acute ischemic left middle cerebral artery stroke
Decision Criteria
clinical Criteria
- Imaging confirms embolism in left MCA.
documentation Criteria
- Documentation specifies 'embolism' and 'left MCA'.
Applicable To
- Acute ischemic stroke due to embolism of left MCA
Excludes
- Cerebral infarction due to thrombosis of left MCA (I63.512)
Clinical Validation Requirements
- MRI showing restricted diffusion in left MCA territory
- CTA confirming embolism in left MCA
Code-Specific Risks
- Incorrectly using unspecified codes when laterality is known
Coding Notes
- Ensure laterality and mechanism (embolism) are documented.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Cerebral infarction due to thrombosis of left middle cerebral artery
I63.512Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Acute Ischemic Left Middle Cerebral Artery Stroke to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code I63.412.
Impact
Clinical: Inaccurate assessment of stroke severity., Regulatory: Non-compliance with CMS requirements., Financial: Potential for reduced reimbursement.
Mitigation Strategy
Ensure NIHSS score is documented at admission and discharge.
Impact
Reimbursement: May lead to reduced reimbursement due to lack of specificity., Compliance: Non-compliance with coding guidelines., Data Quality: Decreases accuracy of clinical data.
Mitigation Strategy
Always specify laterality and mechanism if known.
Impact
Failure to document laterality can lead to audit findings.
Mitigation Strategy
Implement checklist to ensure laterality is documented.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Acute Ischemic Left Middle Cerebral Artery Stroke, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Acute Ischemic Left Middle Cerebral Artery Stroke
Use these documentation templates to ensure complete and accurate documentation for Acute Ischemic Left Middle Cerebral Artery Stroke. These templates include all required elements for proper coding and billing.
Acute Stroke Presentation
Specialty: NeurologyRequired Elements
- Patient demographics
- Onset and duration of symptoms
- NIHSS score
- Imaging results
- Diagnosis
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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