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v1.0.0
ICD-10 Guide
ICD-10 CodesG46.4

G46.4

Billable

Cerebellar stroke syndrome

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/05/2025

Code Description

ICD-10 G46.4 is a billable code used to indicate a diagnosis of cerebellar stroke syndrome.

Key Diagnostic Point:

Cerebellar stroke syndrome refers to a group of neurological symptoms resulting from a stroke affecting the cerebellum, the part of the brain responsible for coordination, balance, and fine motor control. This syndrome can manifest as dizziness, ataxia (lack of voluntary coordination of muscle movements), dysmetria (inability to control the distance of movements), and tremors. Patients may experience difficulty with balance and gait, leading to an increased risk of falls. The cerebellum can be affected by ischemic strokes, which occur when blood flow to the brain is obstructed, or hemorrhagic strokes, which occur when a blood vessel ruptures. Transient ischemic attacks (TIAs) may precede a full-blown stroke, presenting as temporary symptoms that resolve within 24 hours. Stroke prevention strategies include managing risk factors such as hypertension, diabetes, hyperlipidemia, and lifestyle modifications like smoking cessation and regular exercise. Early recognition and treatment of cerebellar stroke syndrome are crucial for minimizing long-term disability and improving patient outcomes.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiating between ischemic and hemorrhagic strokes
  • Identifying transient ischemic attacks (TIAs) versus full strokes
  • Documenting specific neurological deficits
  • Understanding the relationship between risk factors and stroke types

Audit Risk Factors

  • Inadequate documentation of neurological deficits
  • Failure to specify the type of stroke (ischemic vs. hemorrhagic)
  • Misclassification of transient ischemic attacks
  • Lack of documentation supporting the diagnosis

Specialty Focus

Medical Specialties

Neurology

Documentation Requirements

Detailed neurological examination findings, imaging results, and treatment plans.

Common Clinical Scenarios

Patients presenting with acute onset of ataxia, dizziness, or balance issues.

Billing Considerations

Ensure comprehensive documentation of all neurological symptoms and risk factors.

Emergency Medicine

Documentation Requirements

Immediate assessment findings, vital signs, and initial treatment provided.

Common Clinical Scenarios

Patients presenting with acute stroke symptoms requiring rapid intervention.

Billing Considerations

Timely documentation is critical for coding and treatment decisions.

Coding Guidelines

Inclusion Criteria

Use G46.4 When
  • Follow the official ICD
  • CM coding guidelines for cerebrovascular diseases
  • Include documentation of the type of stroke and any associated symptoms
  • Ensure that the diagnosis is supported by clinical findings and imaging studies

Exclusion Criteria

Do NOT use G46.4 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

99285CPT Code

Emergency department visit, high severity

Clinical Scenario

Used for patients presenting with acute stroke symptoms requiring immediate evaluation.

Documentation Requirements

Document the patient's presenting symptoms, examination findings, and any interventions performed.

Specialty Considerations

Emergency medicine specialists should ensure timely and accurate documentation to support coding.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of cerebrovascular conditions, including G46.4, which enhances the ability to capture the nuances of cerebellar stroke syndrome and improve patient care through better data collection.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of cerebrovascular conditions, including G46.4, which enhances the ability to capture the nuances of cerebellar stroke syndrome and improve patient care through better data collection.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of cerebrovascular conditions, including G46.4, which enhances the ability to capture the nuances of cerebellar stroke syndrome and improve patient care through better data collection.

Resources

Clinical References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Coding & Billing References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Frequently Asked Questions

What are the common symptoms of cerebellar stroke syndrome?

Common symptoms include dizziness, ataxia, dysmetria, tremors, and difficulty with balance and coordination.

How can I differentiate between a TIA and a full stroke?

A TIA presents with temporary symptoms that resolve within 24 hours, while a full stroke results in lasting neurological deficits.