ICD-10 Coding for Left MCA Stroke(I63.512, I63.532, I69.351)
Complete ICD-10-CM coding and documentation guide for Left MCA Stroke. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Left MCA Stroke
I63.5Primary Range
Cerebral infarction due to thrombosis or embolism of cerebral arteries
This range includes codes for cerebral infarctions affecting specific arteries, including the left middle cerebral artery.
Sequelae of cerebral infarction
This range is used for coding residual effects following an acute stroke event.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| I63.512 | Cerebral infarction due to thrombosis of left middle cerebral artery | Use when a thrombosis in the left MCA is confirmed by imaging. |
|
| I63.532 | Cerebral infarction due to embolism of left middle cerebral artery | Use when embolism in the left MCA is confirmed by imaging. |
|
| I69.351 | Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side | Use for documenting residual deficits after the acute phase of a left 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 left MCA stroke
Essential facts and insights about Left MCA Stroke
Primary ICD-10-CM Codes for left mca stroke
Decision Criteria
clinical Criteria
- Imaging shows thrombosis in left MCA
documentation Criteria
- Documentation specifies thrombosis
Applicable To
- Acute left MCA thrombosis
Excludes
- Embolism of left MCA
Clinical Validation Requirements
- Imaging confirmation (CT/MRI) of left MCA thrombosis
- NIHSS score indicating significant deficit
Code-Specific Risks
- Misidentifying the cause of the infarction as embolism instead of thrombosis.
Coding Notes
- Ensure the documentation specifies thrombosis as the cause.
I63.532 - Cerebral infarction due to embolism of left middle cerebral artery
Use when embolism in the left MCA is confirmed by imaging.
Applicable To
- Acute left MCA embolism
Excludes
- Thrombosis of left MCA
Clinical Validation Requirements
- CTA/MRA evidence of embolism
- History of embolic source such as atrial fibrillation
Coding Notes
Ensure the documentation specifies embolism as the cause.
I69.351 - Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side
Use for documenting residual deficits after the acute phase of a left MCA stroke.
Applicable To
- Residual right-sided hemiplegia post-left MCA stroke
Excludes
- Acute stroke codes
Clinical Validation Requirements
- Documentation of persistent right-sided weakness
- Linkage to prior left MCA stroke
Coding Notes
Ensure linkage to the initial stroke event is documented.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Unspecified atrial fibrillation
I48.91Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Cerebral infarction due to embolism of left middle cerebral artery
I63.532Cerebral infarction due to thrombosis of left middle cerebral artery
I63.512Hemiplegia and hemiparesis following cerebral infarction affecting left dominant side
I69.352Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Left MCA Stroke to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code I63.512.
Impact
Clinical: Misrepresentation of patient condition, Regulatory: Non-compliance with coding guidelines, Financial: Potential claim denials
Mitigation Strategy
Ensure documentation explicitly links deficits to the stroke, Use sequelae codes appropriately
Impact
Reimbursement: Incorrect code can lead to lower reimbursement rates., Compliance: Non-compliance with coding specificity requirements., Data Quality: Impacts the accuracy of clinical data and reporting.
Mitigation Strategy
Use I63.512 with CTA evidence
Impact
Failure to use specific codes for stroke type and cause.
Mitigation Strategy
Regular training on stroke coding guidelines.
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 Left MCA Stroke, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Left MCA Stroke
Use these documentation templates to ensure complete and accurate documentation for Left MCA Stroke. These templates include all required elements for proper coding and billing.
Emergency Department Note (Stroke Alert)
Specialty: NeurologyRequired Elements
- Chief Complaint
- Imaging Findings
- NIHSS Score
- Treatment Plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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