ICD-10 Coding for Lacunar Infarction and Costovertebral Angle Tenderness(I63.81, R10.819)
Complete ICD-10-CM coding and documentation guide for Lacunar Infarction and Costovertebral Angle Tenderness. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Lacunar Infarction and Costovertebral Angle Tenderness
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| I63.81 | Other cerebral infarction due to occlusion or stenosis of small artery | Use when imaging confirms a lacunar infarct and risk factors for small vessel disease are documented. |
|
| R10.819 | Abdominal tenderness, unspecified site | Use when CVA tenderness is noted without a definitive diagnosis. |
|
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 lacunar infarction
Essential facts and insights about Lacunar Infarction and Costovertebral Angle Tenderness
Primary ICD-10-CM Codes for lacunar costovertebral angle
Decision Criteria
clinical Criteria
- MRI confirmation of lacunar infarct
Applicable To
- Lacunar infarction
Excludes
- Cerebral infarction due to embolism (I63.4-)
Clinical Validation Requirements
- MRI or CT showing <3cm subcortical infarct
- Documentation of small artery disease risk factors
Code-Specific Risks
- Confusion with other types of strokes if 'lacunar' is not specified.
Coding Notes
- Ensure 'lacunar' is specified in the documentation to avoid miscoding.
R10.819 - Abdominal tenderness, unspecified site
Use when CVA tenderness is noted without a definitive diagnosis.
Applicable To
- CVA tenderness
Excludes
- Acute abdomen (R10.0)
Clinical Validation Requirements
- Physical exam showing CVA tenderness
- Supporting labs or imaging for kidney issues
Coding Notes
Document specific findings and associated symptoms to support the use of this code.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Lacunar Infarction and Costovertebral Angle Tenderness to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code I63.81.
Impact
Clinical: May lead to inappropriate treatment focus., Regulatory: Non-compliance with coding specificity requirements., Financial: Potential for claim denials due to lack of specificity.
Mitigation Strategy
Ensure documentation specifies CVA tenderness, Link symptoms to potential renal causes
Impact
Reimbursement: Incorrect coding can lead to denied claims., Compliance: Misinterpretation of clinical context violates coding guidelines., Data Quality: Inaccurate data on patient conditions and treatments.
Mitigation Strategy
Clarify context in documentation to distinguish between cerebrovascular accident and costovertebral angle tenderness.
Impact
Misclassification of stroke types due to vague documentation.
Mitigation Strategy
Educate providers on the importance of specifying stroke types in documentation.
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 Lacunar Infarction and Costovertebral Angle Tenderness, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Lacunar Infarction and Costovertebral Angle Tenderness
Use these documentation templates to ensure complete and accurate documentation for Lacunar Infarction and Costovertebral Angle Tenderness. These templates include all required elements for proper coding and billing.
Lacunar Infarction Diagnosis
Specialty: NeurologyRequired Elements
- Imaging results
- Risk factor history
- NIHSS score
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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