H65.112 - Acute suppurative otitis media without rupture of eardrum, left ear

Clinical Definition

Stroke (cerebral infarction) due to unspecified occlusion or stenosis of a cerebral artery. This represents a brain attack where blood flow is interrupted due to blockage in one of the brain's arteries, but the specific artery is not identified in documentation.

Documentation Requirements

• Must document:

  • Confirmation of stroke through imaging (CT/MRI)

  • Specify if acute, subacute, or chronic

  • Document "cerebral infarction" or "ischemic stroke"

  • Any causal relationship to stenosis/occlusion

  • Presence/absence of residual deficits

  • Dominant vs. non-dominant side affected

  • Initial vs. subsequent encounter

• Should include:

  • NIH Stroke Scale score if available

  • Time of symptom onset

  • Treatment provided (tPA, thrombectomy, etc.)

Common Synonyms

• Brain attack

• Cerebrovascular accident (CVA)

• Stroke

• Brain infarct

• "Blocked artery in brain"

Coding Conflicts

Excludes1:

• Transient cerebral ischemia (TIA)

• Traumatic cerebral infarction

• Hemorrhagic stroke

Excludes2:

• Cerebral atherosclerosis

• Personal history of stroke

Scribing.io Automation

The AI scribe automatically identifies:

• Keywords indicating stroke ("infarct," "CVA," "ischemic stroke")

• Temporal references for acuity

• Anatomical location descriptors

• Treatment modalities

• NIHSS documentation

• Follow-up status indicators

The system will prompt for clarification if:

• Acuity is not specified

• Laterality is unclear

• Cause is not documented

• Initial vs. subsequent encounter is ambiguous