ICD-10 Coding for Lacunar Infarct(I63.81, I65.2)
Complete ICD-10-CM coding and documentation guide for Lacunar Infarct. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Lacunar Infarct
I63.8-I63.81Primary Range
Cerebral infarction due to occlusion or stenosis of small artery
This range includes codes for lacunar infarction, specifically due to small artery occlusion.
Occlusion and stenosis of carotid artery
Used to code carotid artery stenosis, which is not causative for lacunar infarct but may be a comorbidity.
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 a lacunar infarct is confirmed by imaging and attributed to small vessel disease. |
|
| I65.2 | Occlusion and stenosis of carotid artery | Use when carotid stenosis is present but not causative for lacunar infarct. |
|
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 infarct
Essential facts and insights about Lacunar Infarct
Primary ICD-10-CM Codes for lacunar infarct
Decision Criteria
clinical Criteria
- Presence of imaging-confirmed lacunar infarct
documentation Criteria
- Documentation of small vessel disease etiology
Applicable To
- Lacunar infarction
Excludes
- Cerebral infarction due to embolism
Clinical Validation Requirements
- MRI or CT confirmation of lacunar infarct
- Documentation of small vessel disease etiology
Code-Specific Risks
- Incorrectly coding as unspecified cerebral infarction
Coding Notes
- Ensure imaging confirms the lacunar infarct before coding.
I65.2 - Occlusion and stenosis of carotid artery
Use when carotid stenosis is present but not causative for lacunar infarct.
Clinical Validation Requirements
- Imaging showing carotid artery stenosis
Coding Notes
Code separately from lacunar infarct unless explicitly linked.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Other lacunar syndromes
G46.7Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Lacunar Infarct to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code I63.81.
Impact
Clinical: Leads to unspecified diagnosis, Regulatory: Non-compliance with documentation standards, Financial: Potential for lower reimbursement
Mitigation Strategy
Ensure detailed documentation of imaging and clinical findings
Impact
Reimbursement: Incorrect coding may lead to lower reimbursement, Compliance: Non-compliance with coding guidelines, Data Quality: Inaccurate clinical data representation
Mitigation Strategy
Always code I63.81 for confirmed lacunar infarct
Impact
Coding without imaging confirmation may trigger audits
Mitigation Strategy
Ensure all lacunar infarcts are confirmed by imaging
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 Infarct, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Lacunar Infarct
Use these documentation templates to ensure complete and accurate documentation for Lacunar Infarct. These templates include all required elements for proper coding and billing.
Acute lacunar infarct with hypertension
Specialty: NeurologyRequired Elements
- Imaging results
- Clinical symptoms
- Risk factors
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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