Occlusion and stenosis of unspecified vertebral artery

This code signifies a narrowing or blockage within a vertebral artery, the vessels supplying blood to the posterior part of the brain and spinal cord, when the specific vertebral artery (right or left) is not documented. This condition can lead to vertebrobasilar insufficiency, causing symptoms like dizziness, vertigo, and visual disturbances.

Use this code when diagnostic imaging (e.g., CTA, MRA, ultrasound) or clinical assessment confirms occlusion or stenosis of a vertebral artery, but the laterality (right or left) is not specified in the medical record. This applies to both symptomatic and asymptomatic findings.

• Avoid using this code if the laterality of the vertebral artery is documented; instead, use the more specific codes for right (I65.01) or left (I65.02) vertebral artery involvement.
• Always query the provider for laterality if it's missing, as more specific codes offer better data granularity.
• Sequence this code as a primary diagnosis if it's the reason for the encounter, or as a secondary diagnosis if it's a co-morbidity contributing to the patient's overall condition.