AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2020 Issue 3; Ask the Editor

Lacunar Infarction and Carotid Artery Stenosis

We are seeking advice on how to code lacunar stroke when the patient also has carotid stenosis. Our clinicians state that lacunar infarcts result from small vessel brain disease and are never related to carotid artery stenosis, which is a large vessel. For example, a 55-year-old man presented with slurred speech and unsteady gait and the provider diagnosed lacunar stroke. The patient also had moderate stenosis of the right internal carotid artery (ICA). The provider concurred with the radiologist that there was less than 50% stenosis of the right internal carotid artery on computed tomography angiography of the head and indicated it was not clinically significant. When referencing occlusion, artery, carotid, in the Index, there is a subentry “with infarct,” leading to code I63.21, Cerebral infarction due to unspecified occlusion or stenosis of right carotid arteries. This code assignment does not seem clinically correct, since lacunar infarcts are not associated with larger artery stenosis. What is the appropriate code assignment for this case? ...

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