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ICD-10 Guide
ICD-10 CodesI63.311

I63.311

Billable

Cerebral infarction due to thrombosis of right middle cerebral artery

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/06/2025

Code Description

ICD-10 I63.311 is a billable code used to indicate a diagnosis of cerebral infarction due to thrombosis of right middle cerebral artery.

Key Diagnostic Point:

Cerebral infarction due to thrombosis of the right middle cerebral artery (MCA) is a critical condition characterized by the obstruction of blood flow to the brain, specifically affecting the right MCA territory. Clinically, patients may present with sudden onset of neurological deficits, including contralateral hemiparesis, sensory loss, and aphasia, depending on the extent of the infarction. The right MCA supplies blood to significant areas of the brain responsible for motor and sensory functions, as well as language in the dominant hemisphere. Disease progression can lead to irreversible brain damage if not promptly addressed. Diagnostic considerations include neuroimaging techniques such as CT or MRI to confirm the presence of an infarct and to rule out hemorrhagic strokes. Risk factors contributing to thrombosis include hypertension, diabetes, hyperlipidemia, and atrial fibrillation. Timely intervention is crucial to minimize long-term disability and improve patient outcomes.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Diagnostic complexity: Requires imaging and clinical assessment to confirm diagnosis.
  • Treatment complexity: May involve acute management with thrombolytics or anticoagulants, followed by rehabilitation.
  • Documentation requirements: Detailed clinical notes and imaging reports are essential for accurate coding.
  • Coding specificity: Requires precise identification of the affected artery and type of infarction.

Audit Risk Factors

  • Common coding errors: Misidentification of the affected artery or type of stroke.
  • Documentation gaps: Incomplete clinical notes or lack of imaging reports.
  • Billing challenges: Potential denials due to insufficient documentation or coding errors.

Specialty Focus

Medical Specialties

Neurology

Documentation Requirements

Standard ICD-10-CM documentation requirements apply

Common Clinical Scenarios

Various clinical presentations within this specialty area

Billing Considerations

Follow specialty-specific billing guidelines

Emergency Medicine

Documentation Requirements

Standard ICD-10-CM documentation requirements apply

Common Clinical Scenarios

Various clinical presentations within this specialty area

Billing Considerations

Follow specialty-specific billing guidelines

Related ICD-10 Codes

Related CPT Codes

CPT Code

Clinical Scenario

Documentation Requirements

CPT Code

Clinical Scenario

Documentation Requirements

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

Cerebral infarctions, particularly those due to thrombosis of the MCA, have significant clinical implications, contributing to high rates of morbidity and mortality. Understanding the epidemiology of this condition is crucial, as it affects a substantial portion of the population, particularly older adults and those with cardiovascular risk factors. Quality measures focus on timely diagnosis and treatment to improve patient outcomes and reduce healthcare utilization associated with long-term disability.

ICD-9 vs ICD-10

Cerebral infarctions, particularly those due to thrombosis of the MCA, have significant clinical implications, contributing to high rates of morbidity and mortality. Understanding the epidemiology of this condition is crucial, as it affects a substantial portion of the population, particularly older adults and those with cardiovascular risk factors. Quality measures focus on timely diagnosis and treatment to improve patient outcomes and reduce healthcare utilization associated with long-term disability.

Reimbursement & Billing Impact

Reimbursement considerations include the need for accurate coding to reflect the specific type of stroke and its management. Common denials may arise from insufficient documentation or incorrect coding, emphasizing the importance of detailed clinical notes and imaging reports. Best practices include ensuring that all relevant information is captured in the medical record to support the diagnosis and treatment provided.

Resources

Clinical References

  • •
    ICD-10 Official Guidelines for I00-I99
  • •
    Clinical Documentation Requirements

Coding & Billing References

  • •
    ICD-10 Official Guidelines for I00-I99
  • •
    Clinical Documentation Requirements

Frequently Asked Questions

What specific conditions are covered by I63.311?

I63.311 specifically covers cerebral infarction due to thrombosis of the right middle cerebral artery, which may include ischemic strokes resulting from thrombotic occlusion in this specific vascular territory.

When should I63.311 be used instead of related codes?

I63.311 should be used when there is a confirmed diagnosis of cerebral infarction specifically due to thrombosis of the right MCA, distinguishing it from other types of strokes or infarctions affecting different arteries.

What documentation supports I63.311?

Documentation should include clinical notes detailing the patient's symptoms, results from neuroimaging studies confirming the infarction, and any relevant laboratory findings that support the diagnosis of thrombosis.