I61.3
BillableNontraumatic intracerebral hemorrhage in brain stem
HCC Category Mapping
V28HCC 248 — Cerebral Hemorrhage
0.289V24HCC 99 — Intracranial Hemorrhage
0.262ESRDHCC 99 — Intracranial Hemorrhage
0.000What This Code Means
Bleeding within the brain stem, the lower part of the brain that connects to the spinal cord, not caused by trauma.
Coding Tips
- •Brain stem hemorrhage is a distinct location from hemisphere bleeds; ensure documentation specifies brain stem involvement
- •This is a serious condition with high mortality; verify coding accuracy with clinical documentation
Clinical Significance
Nontraumatic intracerebral hemorrhage in the brain stem is one of the most devastating cerebrovascular events, with extremely high mortality and severe disability in survivors. The brain stem controls vital functions including consciousness, breathing, and cardiovascular regulation. This diagnosis reflects the highest acuity of care and has significant implications for risk adjustment and resource utilization.
Documentation Requirements
- ✓Imaging confirmation (CT or MRI) specifically identifying brain stem as the hemorrhage location
- ✓Documentation of nontraumatic etiology, ruling out trauma
- ✓Detailed neurological examination documenting cranial nerve deficits, motor findings, and level of consciousness
- ✓Glasgow Coma Scale score and progression
- ✓Documentation of specific brain stem structures involved (pons, medulla, midbrain) when available
- ✓Treatment plan including critical care management and prognosis discussion
Commonly Confused Codes
I61.4 — Cerebellar hemorrhage; anatomically adjacent but distinct from brain stemI61.0 — Subcortical hemorrhage; deep hemispheric structures, not the brain stemI61.5 — Intraventricular hemorrhage; brain stem hemorrhage may extend into ventricles but should be coded separatelyI61.9 — Unspecified intracerebral hemorrhage; do not use when brain stem is documented as the location
Code Hierarchy
└I61Nontraumatic intracerebral hemorrhage└I61.3Nontraumatic intracerebral hemorrhage in brain stem
└I61.3Nontraumatic intracerebral hemorrhage in brain stem