I63.019
BillableCerebral infarction due to thrombosis of unspecified vertebral artery
HCC Category Mapping
V28HCC 249 — Ischemic or Unspecified Stroke
0.289V24HCC 100 — Ischemic or Unspecified Stroke
0.262ESRDHCC 100 — Ischemic or Unspecified Stroke
0.000What This Code Means
A stroke caused by a blood clot in one of the vertebral arteries (major blood vessels in the neck that supply the brain), but the specific side (left or right) is not documented. This blocks blood flow to the brain and causes brain tissue damage.
Coding Tips
- •Verify documentation to determine if the clot is in the left or right vertebral artery; if specified, use I63.011 (right) or I63.012 (left) instead of the unspecified code I63.019
- •This code requires a principal diagnosis of cerebral infarction and should be supported by imaging confirmation (CT or MRI) and clinical documentation of acute stroke symptoms
Clinical Significance
Cerebral infarction due to thrombosis of an unspecified vertebral artery captures posterior circulation ischemic strokes where vertebral artery thrombosis is confirmed but the laterality (right vs. left) cannot be determined from documentation. This is a documentation quality opportunity as laterality is typically available from imaging. The code still captures the full stroke HCC weight for risk adjustment.
Documentation Requirements
- ✓Imaging confirmation of acute cerebral infarction
- ✓Documentation of vertebral artery thrombosis as the mechanism
- ✓Documentation explaining why laterality could not be determined
- ✓Neurological examination findings consistent with posterior circulation stroke
- ✓Treatment and management plan
- ✓Risk factor assessment and stroke workup
Commonly Confused Codes
I63.011 — Right vertebral artery thrombosis; use when right side is documentedI63.012 — Left vertebral artery thrombosis; use when left side is documentedI63.013 — Bilateral vertebral artery thrombosis; use when both sides involvedI63.119 — Embolism of unspecified vertebral artery; different mechanismI63.00 — Thrombosis of unspecified precerebral artery; even less specific, does not identify the artery
Code Hierarchy
└I63Cerebral infarction└I63.0Cerebral infarction due to thrombosis of precerebral arteries└I63.01Cerebral infarction due to thrombosis of vertebral artery└I63.019Cerebral infarction due to thrombosis of unspecified vertebral artery
└I63.019Cerebral infarction due to thrombosis of unspecified vertebral artery