ICD-10 Coding for Middle Cerebral Artery Stroke(I63.311, I69.351)
Complete ICD-10-CM coding and documentation guide for 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 Middle Cerebral Artery Stroke
I63.3-I63.5Primary Range
Cerebral infarction due to thrombosis or embolism
This range covers acute infarctions of the cerebral arteries, including the middle cerebral artery.
Sequelae of cerebral infarction
This range is used for documenting residual effects following a cerebral infarction.
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 right middle cerebral artery | Use when there is documented thrombosis of the right MCA confirmed by imaging. |
|
| I69.351 | Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side | Use for documenting residual hemiplegia following a right MCA 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 MCA stroke
Essential facts and insights about Middle Cerebral Artery Stroke
Primary ICD-10-CM Codes for dopplers middle cerebral artery dopplers stroke
Decision Criteria
clinical Criteria
- Documented thrombosis of right MCA with imaging confirmation.
Applicable To
- Thrombosis of right MCA
Excludes
- Transient ischemic attack (G45.9)
Clinical Validation Requirements
- TCD showing mean flow velocity >100 cm/s in right MCA
- CT/MRI confirming infarction in MCA territory
Code-Specific Risks
- Risk of using unspecified codes when specific documentation is available.
Coding Notes
- Ensure laterality and dominance are documented for accurate coding.
I69.351 - Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side
Use for documenting residual hemiplegia following a right MCA stroke.
Applicable To
- Residual hemiplegia following right MCA stroke
Excludes
- Hemiplegia due to other causes
Clinical Validation Requirements
- NIHSS score indicating hemiplegia
- Documentation of residual weakness post-stroke
Coding Notes
Document the affected side and dominance clearly.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits
Z86.73Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Middle Cerebral Artery Stroke to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code I63.311.
Impact
Clinical: May lead to inappropriate treatment decisions., Regulatory: Non-compliance with documentation standards., Financial: Potential for denied claims or reduced reimbursement.
Mitigation Strategy
Use standardized templates for stroke documentation., Train staff on the importance of detailed documentation.
Impact
Reimbursement: May lead to lower DRG assignment and reimbursement., Compliance: Non-compliance with coding guidelines., Data Quality: Decreases accuracy of clinical data.
Mitigation Strategy
Ensure detailed documentation of the affected artery, laterality, and dominance.
Impact
Incomplete documentation of stroke details can lead to audit issues.
Mitigation Strategy
Implement comprehensive documentation checklists.
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 Middle Cerebral Artery Stroke, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Middle Cerebral Artery Stroke
Use these documentation templates to ensure complete and accurate documentation for Middle Cerebral Artery Stroke. These templates include all required elements for proper coding and billing.
Acute MCA Stroke
Specialty: NeurologyRequired Elements
- Onset time
- Symptoms
- Imaging results
- TCD findings
- NIHSS score
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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