ICD-10 Coding for Acute Left ICA Stroke Syndrome(I63.311, I63.411)
Complete ICD-10-CM coding and documentation guide for Acute Left ICA Stroke Syndrome. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Acute Left ICA Stroke Syndrome
I63.3-I63.5Primary Range
Cerebral infarction due to thrombosis or embolism of cerebral arteries
This range includes codes for cerebral infarctions due to thrombosis or embolism, specifically affecting the left internal carotid artery.
Sequelae of cerebral infarction
Used for documenting residual effects after the acute phase of a stroke.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| I63.311 | Cerebral infarction due to thrombosis of left internal carotid artery | Use when imaging confirms thrombosis of the left ICA causing an acute ischemic stroke. |
|
| I63.411 | Cerebral infarction due to embolism of left internal carotid artery | Use when imaging confirms embolism of the left ICA causing an acute ischemic stroke. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for acute left ICA stroke syndrome
Essential facts and insights about Acute Left ICA Stroke Syndrome
Primary ICD-10-CM Codes for acute left ica stroke syndrome
Decision Criteria
clinical Criteria
- Confirmed thrombosis of left ICA on imaging
documentation Criteria
- Detailed documentation of stroke symptoms and imaging findings
Applicable To
- Thrombosis of left ICA with infarction
Excludes
- Embolism of left ICA (I63.411)
Clinical Validation Requirements
- Imaging (CTA/MRA) confirming left ICA thrombosis
- Clinical presentation of ischemic stroke in left MCA territory
Code-Specific Risks
- Incorrectly using unspecified codes when specific imaging is available
Coding Notes
- Ensure imaging confirms the specific cause (thrombosis vs embolism) before coding.
I63.411 - Cerebral infarction due to embolism of left internal carotid artery
Use when imaging confirms embolism of the left ICA causing an acute ischemic stroke.
Applicable To
- Embolism of left ICA with infarction
Excludes
- Thrombosis of left ICA (I63.311)
Clinical Validation Requirements
- Imaging (CTA/MRA) confirming left ICA embolism
- Clinical presentation of ischemic stroke in left MCA territory
Coding Notes
Ensure imaging confirms the specific cause (embolism vs thrombosis) before coding.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Hemiplegia/hemiparesis following cerebral infarction affecting right dominant side
I69.351Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Acute Left ICA Stroke Syndrome to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code I63.311.
Impact
Clinical: May affect treatment decisions and outcome tracking., Regulatory: Non-compliance with stroke quality measures., Financial: Potential loss of reimbursement linked to stroke severity.
Mitigation Strategy
Include NIHSS score in all initial assessments, Regular training on stroke documentation
Impact
Reimbursement: Can lead to lower reimbursement rates due to less specific DRG assignment., Compliance: May result in compliance issues during audits., Data Quality: Reduces the accuracy of clinical data for research and quality measures.
Mitigation Strategy
Always confirm the specific cause (thrombosis vs embolism) with imaging before coding.
Impact
Audits may focus on the specificity of stroke coding, particularly regarding the cause and laterality.
Mitigation Strategy
Ensure thorough documentation of imaging findings and clinical correlation.
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 Left ICA Stroke Syndrome, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Acute Left ICA Stroke Syndrome
Use these documentation templates to ensure complete and accurate documentation for Acute Left ICA Stroke Syndrome. These templates include all required elements for proper coding and billing.
Acute Stroke Presentation in Emergency Department
Specialty: NeurologyRequired Elements
- Patient history
- Imaging findings
- NIHSS score
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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