Unspecified sequelae of cerebral infarction

This code signifies a long-term, residual effect or complication stemming from a cerebral infarction (ischemic stroke) where the specific nature of the sequela is not documented or is unknown. It indicates that the patient is experiencing ongoing issues directly attributable to a past stroke event.

Use this code when documentation clearly links a current symptom or condition to a previous cerebral infarction, but the specific type of sequela (e.g., hemiplegia, aphasia) is not specified. This is appropriate when the medical record states "sequelae of cerebral infarction, unspecified" or similar broad terms.

• Avoid using this code if a more specific sequela (e.g., hemiplegia, aphasia, dysphagia) is documented; always code to the highest level of specificity.
• Always sequence this code after the acute stroke code (if still in the acute phase) or as a primary diagnosis when the sequela is the reason for the encounter.
• Query the provider for more specific documentation of the sequela whenever possible to allow for more precise coding.