Neurosurgery Coding Alert

You Be the Coder:

Deciphering Diagnosis Code Notes

Question: Encounter notes indicate that a patient suffered a fracture Encounter notes indicate that the provider treated a patient for “CI due to embol, mid-cerebral artery.” What is the correct ICD-10 code for this patient?

Wisconsin Subscriber

Answer: The shorthand your provider used points to a cerebral infarction (CI) due to embolism (embol) in the middle cerebral artery (mid-cerebral artery). On the claim, you’ll want to choose from the following ICD-10 codes, depending on location of the embolism:

  • I63.411 (Cerebral infarction due to embolism of right middle cerebral artery)
  • I63.412 (Cerebral infarction due to embolism of left middle cerebral artery)
  • I63.413 (Cerebral infarction due to embolism of bilateral middle cerebral arteries)
  • I63.419 (Cerebral infarction due to embolism of unspecified middle cerebral artery)