Neurosurgery Coding Alert

Reader Questions:

Code for Laterality on Stroke Dx

Question: I’m new to neurosurgery coding, and I was wondering if you could offer tips on coding for strokes?

Florida Subscriber

Answer: When a patient presents with a stroke — or cerebral infarction (CI) — you’ll head to the I63.- (Cerebral infarction) code set.

The CI set contains diagnosis codes for several stroke types, including:

  • 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)
  • 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)

You’ll use the 5th character of your stroke diagnosis to represent specifics such as stenosis or embolism. Stroke diagnoses nearly always go to the 6th character, which identifies laterality: right (1); left (2); bilateral (3); or unspecified (9).