ICD-10 Coding for Vertebral Artery Occlusion(I65.01, I65.02, I65.03, I65.09)
Complete ICD-10-CM coding and documentation guide for Vertebral Artery Occlusion. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Vertebral Artery Occlusion
I65.0-I65.9Primary Range
Occlusion and stenosis of precerebral arteries, not resulting in cerebral infarction
This range includes codes for vertebral artery occlusion without infarction.
Cerebral infarction due to occlusion or stenosis of vertebral or basilar arteries
Used when vertebral artery occlusion results in 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 |
|---|---|---|---|
| I65.01 | Occlusion and stenosis of right vertebral artery | Use when there is occlusion or stenosis of the right vertebral artery without infarction. |
|
| I65.02 | Occlusion and stenosis of left vertebral artery | Use when there is occlusion or stenosis of the left vertebral artery without infarction. |
|
| I65.03 | Occlusion and stenosis of bilateral vertebral arteries | Use when there is occlusion or stenosis of both vertebral arteries without infarction. |
|
| I65.09 | Occlusion and stenosis of unspecified vertebral artery | Use when laterality is not specified, but occlusion or stenosis is confirmed. |
|
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 vertebral artery occlusion
Essential facts and insights about Vertebral Artery Occlusion
Primary ICD-10-CM Codes for vertebral artery occlusion
Decision Criteria
clinical Criteria
- Imaging shows occlusion without infarction
Applicable To
- Right vertebral artery stenosis
- Right vertebral artery occlusion
Excludes
- Cerebral infarction due to vertebral artery occlusion (I63.53)
Clinical Validation Requirements
- Imaging confirmation of right vertebral artery occlusion
- Absence of cerebral infarction on MRI/CT
Code-Specific Risks
- Incorrectly coding when infarction is present
Coding Notes
- Ensure laterality is specified to avoid defaulting to unspecified codes.
I65.02 - Occlusion and stenosis of left vertebral artery
Use when there is occlusion or stenosis of the left vertebral artery without infarction.
Applicable To
- Left vertebral artery stenosis
- Left vertebral artery occlusion
Excludes
- Cerebral infarction due to vertebral artery occlusion (I63.53)
Clinical Validation Requirements
- Imaging confirmation of left vertebral artery occlusion
- Absence of cerebral infarction on MRI/CT
Coding Notes
Ensure laterality is specified to avoid defaulting to unspecified codes.
I65.03 - Occlusion and stenosis of bilateral vertebral arteries
Use when there is occlusion or stenosis of both vertebral arteries without infarction.
Applicable To
- Bilateral vertebral artery stenosis
- Bilateral vertebral artery occlusion
Excludes
- Cerebral infarction due to vertebral artery occlusion (I63.53)
Clinical Validation Requirements
- Imaging confirmation of bilateral vertebral artery occlusion
- Absence of cerebral infarction on MRI/CT
Coding Notes
Ensure laterality is specified to avoid defaulting to unspecified codes.
I65.09 - Occlusion and stenosis of unspecified vertebral artery
Use when laterality is not specified, but occlusion or stenosis is confirmed.
Applicable To
- Unspecified vertebral artery stenosis
- Unspecified vertebral artery occlusion
Excludes
- Cerebral infarction due to vertebral artery occlusion (I63.53)
Clinical Validation Requirements
- Imaging confirmation of vertebral artery occlusion
- Absence of cerebral infarction on MRI/CT
Coding Notes
Avoid using this code when laterality can be specified.
Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Cerebral infarction due to vertebral artery occlusion
I63.53Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Vertebral Artery Occlusion to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code I65.01.
Impact
Clinical: May lead to incorrect diagnosis and treatment., Regulatory: Non-compliance with coding standards., Financial: Potential for denied claims.
Mitigation Strategy
Ensure imaging results are included in the patient's record., Verify documentation before coding.
Impact
Reimbursement: Incorrect coding can lead to reduced reimbursement., Compliance: Failure to comply with specificity requirements., Data Quality: Decreases the accuracy of patient records.
Mitigation Strategy
Always specify laterality to use the correct code (I65.01, I65.02, I65.03).
Impact
Reimbursement: Incorrect DRG assignment affects payment., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data reporting.
Mitigation Strategy
Use I63.53 when cerebral infarction is due to vertebral artery occlusion.
Impact
Risk of audits due to lack of specificity in coding vertebral artery occlusions.
Mitigation Strategy
Ensure documentation includes laterality and imaging confirmation.
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 Vertebral Artery Occlusion, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Vertebral Artery Occlusion
Use these documentation templates to ensure complete and accurate documentation for Vertebral Artery Occlusion. These templates include all required elements for proper coding and billing.
Emergency Department Presentation
Specialty: Emergency MedicineRequired Elements
- Neurological symptoms
- Imaging findings
- Etiology
- Dominance
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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