ICD-10 Coding for Basilar Artery Stenosis(I65.1, I63.5-)
Complete ICD-10-CM coding and documentation guide for Basilar Artery Stenosis. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Basilar Artery Stenosis
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| I65.1 | Occlusion and stenosis of basilar artery | Use when imaging confirms stenosis without acute infarction. |
|
| I63.5- | Cerebral infarction due to occlusion/stenosis of basilar artery | Use when infarction is present and linked to stenosis. |
|
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 basilar artery stenosis
Essential facts and insights about Basilar Artery Stenosis
Primary ICD-10-CM Codes for basilar artery stenosis
Decision Criteria
clinical Criteria
- Imaging shows ≥50% stenosis without infarction.
documentation Criteria
- Symptoms documented without permanent deficits.
Applicable To
- Basilar artery stenosis without infarction
Excludes
- Cerebral infarction due to basilar artery stenosis (I63.5-)
Clinical Validation Requirements
- Imaging confirmation of ≥50% stenosis without infarction
- Symptoms such as transient dizziness or diplopia without permanent deficits
Code-Specific Risks
- Misclassification if infarction is present but not documented.
Coding Notes
- Ensure documentation specifies no infarction for I65.1.
I63.5- - Cerebral infarction due to occlusion/stenosis of basilar artery
Use when infarction is present and linked to stenosis.
Applicable To
- Infarction due to basilar artery stenosis
Excludes
- Stenosis without infarction (I65.1)
Clinical Validation Requirements
- MRI/CT confirms acute infarction in posterior circulation territories
- Documentation links stenosis to infarction
Coding Notes
Ensure documentation explicitly links stenosis to infarction.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Cerebral atherosclerosis
I67.1Differential 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 Basilar Artery Stenosis to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code I65.1.
Impact
Clinical: Mismanagement of patient treatment plans., Regulatory: Non-compliance with coding standards., Financial: Potential for incorrect billing and reimbursement.
Mitigation Strategy
Ensure thorough documentation of imaging findings., Link symptoms to imaging results.
Impact
Reimbursement: Incorrect DRG assignment can lead to overpayment or underpayment., Compliance: Non-compliance with ICD-10 coding guidelines., Data Quality: Inaccurate clinical data affecting patient records.
Mitigation Strategy
Use I65.1 for stenosis without infarction.
Impact
Coding infarction without documented evidence.
Mitigation Strategy
Require imaging confirmation before coding.
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 Basilar Artery Stenosis, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Basilar Artery Stenosis
Use these documentation templates to ensure complete and accurate documentation for Basilar Artery Stenosis. These templates include all required elements for proper coding and billing.
Basilar artery stenosis without infarction
Specialty: NeurologyRequired Elements
- Imaging results
- Symptom description
- Stenosis severity
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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