Documenting and Coding Cerebrovascular Disease

by | Published on May 30, 2019 | Resources | 0 comments

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Cerebrovascular disease is a condition that causes temporary or permanent block of blood flow in the brain. Stroke is a type of cerebrovascular disorder. According to the Internet Stroke Center, stroke causes more than 140,000 deaths each year in the US, and the condition is the leading cause of serious, long-term disability in the country. For reimbursement purposes and also to provide better patient care, physicians need to provide accurate documentation and use the correct ICD-10 codes to describe the patient’s condition. Outsourcing medical billing and coding to an experienced service provider is the best option to achieve these goals.

Symptoms and Risk Factors

The signs and symptoms of cerebrovascular disease depend on where the blockage occurs, and the extent of cerebral tissue affected. Blood flow in the brain can be restricted due to various reasons:

  • The formation of clots may form (thrombosis)
  • The narrowing of the vessels may narrow (stenosis)
  • A blockage (embolism); or
  • Bursting of a blood vessel (hemorrhage)

High blood pressure is a major risk factor for a cerebrovascular disorder such as a stroke. Other risk factors include older age, family history of cerebrovascular disease, obesity, diabetes, high cholesterol, atrial fibrillation, drug abuse, smoking, and high cholesterol. Men also have a higher risk.


A cerebrovascular disorder is diagnosed based on the following symptoms:

  • Severe and sudden headache
  • Paralysis of one side (hemiplegia)
  • Weakness on one side (hemiparesis)
  • Abnormal or slurred speech
  • Confusion
  • Dizziness or nausea
  • Vision problems
  • Numbness
  • Loss of balance
  • Loss of consciousness


The patient’s pulse may be checked in various places to identify areas with blood flow problems. Tests ordered to diagnose a cerebrovascular disorder include cerebral angiography and imaging tests, such as MRIs or CT scans.

ICD-10 Codes for Cerebrovascular diseases

The ICD-10 codes for cerebrovascular diseases are included in I60–I69. Coding correctly for Ischemic and Unspecified Stroke is crucial to show which patients are sicker and are at a higher risk. The ICD-10 stroke codes offer higher specificity. Physicians must ensure more specific clinical documentation so that medical coding service providers can choose the right codes. In ICD-10, cerebrovascular disease codes are classified as follows:

  • I60-162 – Non-traumatic intracranial hemorrhage
  • I63 – Cerebral infarctions
  • I65-I66 – Occlusion and stenosis of cerebral of precerebral vessels without infarction
  • I67-I68 – Other cerebrovascular diseases
  • I69 – Sequelae of cerebrovascular disease (late effect)

Code category I63 describes the following:

  • Cause of the ischemic stroke
  • Specific location and laterality of the occlusion

I63 Cerebral infarction
I63.0 Cerebral infarction due to thrombosis of precerebral arteries
I63.1 Cerebral infarction due to embolism of precerebral arteries
I63.2 Cerebral infarction due to unspecified occlusion or stenosis of precerebral arteries

Specific arteries for 163.0-163.2 should be identified with a fifth character:

Unspecified precerebral artery 163.0
Vertebral artery 163.-1
Basilar artery 163.2-2
Carotid artery 163.-3

Other precerebral artery 163.-9

I63.3 Cerebral infarction due to thrombosis of cerebral arteries
I63.4 Cerebral infarction due to embolism of cerebral arteries
I63.5 Cerebral infarction due to unspecified occlusion or stenosis of cerebral arteries
I63.6 Cerebral infarction due to cerebral venous thrombosis, nonpyogenic
I63.8 Other cerebral infarction
I63.9 Cerebral infarction, unspecified

When applicable, laterality for 163.0-163.5 must be specified:

Right – 163.-1
Left 163.-2
Unspecified 163.-9

  • Code category I65-I66 also requires the documentation to specify whether an occlusion or stenosis involves the precerebral arteries or the cerebral arteries.
  • Code category I67-I68 describes other cerebrovascular diseases and cerebrovascular disorders in diseases classified elsewhere.
  • Code category I69 (Sequelae of cerebrovascular disease) specifies the type of stroke that caused the sequelae (late effect) as well as the residual condition itself. Category I69 codes also indicate whether the dominant or non-dominant side is affected.

Reporting codes in category 169

Blue Cross and Blue Shield of Alabama (BCCSAL) provides the following information on assigning codes in category 169 (Sequelae of cerebrovascular disease):

ICD-10 codes in category I69 describe the type of stroke and the sequelae (late effect) caused by the stroke. According to coding guidelines, the sequelae caused by a stroke may be present from the onset of a stroke or arise at any time after the onset of the stroke.

  • The physician should clearly document the side of the body affected so that sequelae (late effect) of cerebrovascular disease can be correctly coded.
  • The clinical documentation should also clearly specify whether a neurological deficit is directly related to cerebrovascular disease or is a cerebrovascular accident.
  • Codes under category I69 are to be used only in conjunction with codes from categories I60-I68 (Cerebrovascular diseases) if a patient has a current cerebrovascular disease and also has late effects from an old cerebrovascular disease.
  • If the patient has a current cerebrovascular disease and late effects from an old cerebrovascular disease, a code from category I69 can be assigned in conjunction with a condition classifiable to code category I60-I67.

There are many more rules for reporting cerebrovascular diseases. Selection of the right ICD-10 codes is important for correctly describing the patient’s condition. Partnering with an experienced medical coding company can help healthcare provider ensure complete and accurate documentation and code assignment.

Natalie Tornese

Holding a CPC certification from the American Academy of Professional Coders (AAPC), Natalie is a seasoned professional actively managing medical billing, medical coding, verification, and authorization services at OSI.

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