I63.039
BillableCerebral infarction due to thrombosis of unspecified carotid 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 a carotid artery, but the specific side (right or left) is not documented.
Coding Tips
- •Use this code only when carotid artery involvement is confirmed but laterality cannot be determined
- •Review imaging reports to determine if laterality can be specified for more precise coding
Clinical Significance
Cerebral infarction due to thrombosis of an unspecified carotid artery captures ischemic strokes where carotid artery thrombosis is confirmed as the mechanism but the laterality is not documented. Carotid artery strokes are among the most common stroke subtypes, and laterality is almost always determinable from imaging. This code represents a documentation quality opportunity while still capturing the full risk adjustment value.
Documentation Requirements
- ✓Imaging confirmation of acute cerebral infarction
- ✓Documentation of carotid artery thrombosis as the stroke mechanism
- ✓Explanation of why laterality could not be determined
- ✓Neurological examination findings
- ✓Treatment documentation
- ✓Plan for follow-up imaging to clarify laterality if possible
Commonly Confused Codes
I63.031 — Right carotid artery thrombosis; use when right side is documentedI63.032 — Left carotid artery thrombosis; use when left side is documentedI63.033 — Bilateral carotid artery thrombosis; use when both sides are involvedI63.139 — Embolism of unspecified carotid artery; different mechanismI63.00 — Thrombosis of unspecified precerebral artery; does not even identify the carotid
Code Hierarchy
└I63Cerebral infarction└I63.0Cerebral infarction due to thrombosis of precerebral arteries└I63.03Cerebral infarction due to thrombosis of carotid artery└I63.039Cerebral infarction due to thrombosis of unspecified carotid artery
└I63.039Cerebral infarction due to thrombosis of unspecified carotid artery