I69.312

🧬 ICD-10 CM I69.312 — Visuospatial Deficit and Spatial Neglect Following Cerebral Infarction

Billable Code Confirmed

ICD-10 CM I69.312 is a valid, fully billable 7-character ICD-10-CM diagnosis code effective for FY2026. It belongs to the I69 category (Sequelae of Cerebrovascular Disease) and specifically identifies cognitive deficits of the visuospatial and spatial neglect type arising as a late effect of a cerebral infarction. The 7th character structure of I69.312 provides the specificity required for billing — no additional characters are needed. This code is appropriate for use after the acute inpatient stroke encounter has concluded, when documenting residual neurological sequelae.^1,2

Non-Billable Parent Codes

I69 (Sequelae of cerebrovascular disease) — This is a 3-character category header and is non-billable; it requires subcategory and full code specificity to be submitted on a claim.¹ I69.3 (Sequelae of cerebral infarction) — This 4-character subcategory is non-billable as it lacks the specificity needed to identify the type of sequela; additional characters are required.¹ I69.31 (Cognitive deficits following cerebral infarction) — This 5-character subcategory is non-billable; it groups cognitive deficit sequelae but must be extended to specify the exact cognitive deficit type.¹

Clinical Context

ICD-10 CM I69.312 captures the specific residual cognitive impairment of visuospatial processing and spatial neglect — a neuropsychological syndrome distinct from motor or speech sequelae. Visuospatial deficits affect the patient’s ability to perceive and interpret spatial relationships, while spatial (hemispatial) neglect represents a failure to attend to stimuli on one side of space, most commonly contralateral to a right hemisphere infarction. This distinction is clinically significant: spatial neglect is associated with worse functional rehabilitation outcomes and longer inpatient stays compared to motor deficits alone. Documenting and coding this condition specifically supports accurate post-acute care referrals and inpatient rehabilitation justification.^3,4

Code Classification

ICD-10 CM I69.312 is a diagnosis code classifying a sequela (late effect) of a cerebrovascular accident — it is not a procedure code and is not an acute condition code. It must only be assigned when a documented causal relationship exists between the prior cerebral infarction and the current visuospatial/spatial neglect deficit; this linkage must be explicitly supported in provider documentation per ICD-10-CM Official Guidelines.^1,2

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🔍 Code Description

ICD-10 CM I69.312 identifies visuospatial deficit and spatial neglect as residual manifestations of a prior cerebral infarction. Visuospatial deficit refers to impaired ability to process, interpret, and interact with spatial information in the environment — patients may struggle with depth perception, object location, navigation, and reading spatial maps. These deficits arise because the infarcted brain tissue, particularly in the right parietal or occipital lobes, can no longer support the neural networks responsible for spatial processing. The code sits within the I69.31x subcategory, which encompasses all cognitive deficit sequelae of cerebral infarction, alongside attention deficits (I69.310), memory deficits (I69.311), psychomotor deficits (I69.313), and frontal lobe deficits (I69.314).^1,2,3

Spatial neglect, the second component captured by this code, is a clinically distinct syndrome in which the patient fails to report, respond to, or orient toward stimuli on the side contralateral to the brain lesion — most frequently the left side following right hemisphere infarction. This is not a visual field deficit (which would be coded separately) but rather an attentional and representational failure rooted in damage to the right temporoparietal junction and associated networks. Spatial neglect is one of the strongest negative predictors of functional independence after stroke, making its accurate documentation critical for justifying inpatient rehabilitation, skilled nursing facility placement, and occupational therapy services. Coders should look for documentation of hemispatial neglect, unilateral neglect, visuospatial processing impairment, or specific neuropsychological testing results (e.g., line bisection test, clock drawing) in the provider notes to support assignment of this code.^3,4

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🌳 Code Tree / Hierarchy

I69 — Sequelae of cerebrovascular disease ❌ Non-billable
│
├── I69.0 — Sequelae of nontraumatic subarachnoid hemorrhage ❌ Non-billable
├── I69.1 — Sequelae of nontraumatic intracerebral hemorrhage ❌ Non-billable
├── I69.2 — Sequelae of other nontraumatic intracranial hemorrhage ❌ Non-billable
│
├── I69.3 — Sequelae of cerebral infarction ❌ Non-billable
│   │
│   ├── I69.30 — Unspecified sequelae of cerebral infarction ✅ Billable
│   │
│   ├── I69.31 — Cognitive deficits following cerebral infarction ❌ Non-billable
│   │   │
│   │   ├── I69.310 — Attention and concentration deficit following cerebral infarction ✅ Billable
│   │   ├── I69.311 — Memory deficit following cerebral infarction ✅ Billable
│   │   ├── I69.312 — Visuospatial deficit and spatial neglect following cerebral infarction ◀ THIS CODE ✅ Billable
│   │   ├── I69.313 — Psychomotor deficit following cerebral infarction ✅ Billable
│   │   ├── I69.314 — Frontal lobe and executive function deficit following cerebral infarction ✅ Billable
│   │   ├── I69.315 — Cognitive social or emotional deficit following cerebral infarction ✅ Billable
│   │   └── I69.318 — Other symptoms and signs involving cognitive functions following CI ✅ Billable
│   │
│   ├── I69.32 — Speech and language deficits following cerebral infarction ❌ Non-billable
│   └── I69.39 — Other sequelae of cerebral infarction ❌ Non-billable
│
└── I69.8 — Sequelae of other cerebrovascular diseases ❌ Non-billable

Laterality Doesn't Apply Here — But Neglect Side Matters Clinically

Unlike motor sequelae codes (e.g., hemiplegia codes under I69.35x), I69.312 does not include a laterality character — you cannot specify left vs. right spatial neglect with this code alone. However, clinically, left-sided spatial neglect (right hemisphere infarct) carries the heaviest functional burden and worst rehabilitation prognosis; make sure the provider documents the side affected and the hemisphere of infarction to support the full clinical picture, even though the ICD-10-CM code itself doesn’t differentiate.^1,3

Don't Default to I69.30 (Unspecified)

When the provider documents specific visuospatial or spatial neglect deficits supported by neuropsych testing or occupational therapy evaluation, I69.312 must be selected over the unspecified I69.30. Specificity in sequela coding is required by ICD-10-CM Official Guidelines Section I.C.9 and payers may reject or down-code claims with nonspecific sequela codes when more specific alternatives clearly apply.²

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✅ Includes

• Visuospatial processing deficit post-CI: Any documented impairment in the patient’s ability to perceive, judge, or interact with spatial relationships following a confirmed cerebral infarction is captured here.¹
• Hemispatial neglect / unilateral neglect following CI: Failure to attend to or respond to stimuli on one side of space as a direct residual effect of the infarction; this is an attentional deficit, not solely a visual one.³
• Constructional apraxia secondary to CI: Difficulty copying drawings or assembling objects due to spatial processing failure can be captured under this code when linked to a prior infarction.⁴
• Topographic disorientation following CI: An inability to navigate familiar environments secondary to spatial processing breakdown after cerebral infarction falls within the visuospatial deficit concept of this code.³
• Post-stroke spatial neglect documented by neuropsychological testing: Results from standardized tests (line bisection, cancellation tasks, clock drawing) supporting a diagnosis of spatial neglect following CI are valid clinical anchors for this code.⁴

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❌ Excludes

Excludes 1

• Z86.73 — Personal history of cerebral infarction without residual deficit: This code is mutually exclusive with I69.312 and may never be reported on the same claim. Z86.73 is used only when the prior stroke left no residual deficits — by definition, if visuospatial neglect persists, a residual deficit exists and I69.312 applies instead. Assigning both codes simultaneously is a direct coding error and an NCCI violation risk.^1,2
• S06.- — Sequelae of traumatic intracranial injury: If spatial neglect or visuospatial deficits arise from a traumatic brain injury rather than an ischemic infarction, codes from the S06 category must be used; I69.312 is restricted to sequelae of non-traumatic cerebral infarction (I63.x etiology). Mixing these categories is one of the most common auditor-flagged errors in cerebrovascular sequela coding.^1,2

Most Common Excludes 1 Error

The most frequent error seen in inpatient and outpatient records is assigning bothZ86.73 and I69.312 on the same encounter. Coders sometimes apply Z86.73 as a “history” code while simultaneously coding active sequelae — this is incorrect. The moment a residual deficit like visuospatial neglect is documented and coded, Z86.73 is off the table for that encounter. This error can trigger claim edits, audits, and potential fraud flags under RAC and OIG review.^1,2

Excludes 2

• There are no formal Excludes 2 notations attached specifically to I69.312. However, per ICD-10-CM guidelines, visual field deficits (e.g., H53.4x — Visual field defects) may be coded separately alongside I69.312 if both conditions are documented, since visual field loss is a distinct anatomical condition separate from the attentional/spatial neglect syndrome captured by I69.312.^1,2

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📋 Clinical Overview

Visuospatial Deficit vs. Related Cognitive Sequelae

Post-stroke cognitive sequelae are not monolithic — ICD-10-CM intentionally differentiates between attention, memory, visuospatial, psychomotor, frontal lobe, and social-emotional deficits because each has distinct clinical management pathways and functional implications. Visuospatial deficit and spatial neglect specifically impair the patient’s interaction with physical space rather than language or memory, making them uniquely impactful for mobility, ADL performance, and driving ability. CDI specialists should query providers when the record reflects OT or neuropsych findings consistent with spatial neglect but the attending documentation only states “cognitive impairment” or “neurological deficits NOS.”^3,4

Feature	I69.312	I69.310	I69.311
Deficit Type	Visuospatial processing and spatial attention	Attention and concentration	Memory encoding and retrieval
Primary Brain Region Affected	Right parietal/temporoparietal junction; occipital cortex	Frontal-subcortical circuits; thalamic pathways	Hippocampus; medial temporal lobe; thalamus
Common Clinical Signs	Line bisection errors, neglect of left hemispace, difficulty copying figures, topographic disorientation	Distractibility, inability to sustain focus, poor dual-tasking	Anterograde amnesia, poor recall, repetitive questioning
Rehab Impact	High — strongly predicts poor functional independence; may contraindicate certain ADL training approaches	Moderate — responds to structured cue-based strategies	Moderate-High — impacts new learning for therapy carryover
Coding Trigger in Documentation	”Spatial neglect,” “hemispatial neglect,” “visuospatial deficit,” OT/neuropsych testing results	”Attention deficit,” “concentration deficit,” “poor sustained attention post-stroke"	"Memory deficit,” “short-term memory loss following stroke,” “amnestic syndrome”

CDI Query Trigger

When the occupational therapy or neuropsychology consult note documents spatial neglect or visuospatial impairment but the attending physician’s progress notes only state “history of stroke” or “post-stroke deficits,” a CDI query is warranted to establish the causal link between the prior infarction and the current cognitive deficit. ICD-10-CM Official Guidelines require that the provider explicitly link the sequela to the prior infarction — implied associations are insufficient for I69.x code assignment in an audit context.^1,2

Manifestations & Symptom Burden

• Hemispatial neglect: Patient fails to acknowledge, respond to, or orient toward stimuli in the contralateral hemispace — most commonly left-sided neglect following right MCA territory infarction; can affect reading, eating, grooming, and mobility.³
• Constructional impairment: Difficulty reproducing drawings, assembling objects, or copying geometric figures due to spatial mapping failure rather than motor weakness.⁴
• Topographic disorientation: Patient cannot navigate previously familiar environments, find their hospital room, or use a map; this arises from breakdown of spatial representational networks.³
• Dressing apraxia: Inability to correctly orient clothing to the body, a spatial-motor integration failure often co-occurring with spatial neglect; may be documented by OT and supports this code.⁴
• Reading and writing errors (spatial dyslexia/dysgraphia): Omitting the left side of words or lines of text, a reading manifestation of left hemispatial neglect; distinguishable from language-based alexia.³

Manifestation Coding Rules for I69.312

ICD-10 CM I69.312 is itself the sequela code — it IS the manifestation code for this scenario. Per ICD-10-CM sequela coding rules (Section I.B.10), no separate “cause” code for the original infarction is required when assigning I69.312, because the “following cerebral infarction” language is built into the code descriptor. Do not add a redundant I63.x code unless the patient is being seen for a new, active acute infarction occurring simultaneously. However, if additional distinct manifestations exist (e.g., hemiplegia, aphasia), each should be coded separately with its own I69.3xx code.^1,2

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💰 HCC Risk Adjustment

Model	HCC Category	HCC Label	RAF Value
CMS-HCC (Medicare Advantage)	Not Mapped	N/A	0.000
HHS-HCC (ACA/Marketplace)	Not Mapped	N/A	0.000
RxHCC	Not Mapped	N/A	0.000

ICD-10 CM I69.312 does not generate a Risk Adjustment Factor score under any current CMS risk adjustment model. Per Blue Cross NC guidance and CMS documentation, all codes in the I69.30–I69.328 range (cognitive deficit sequelae of cerebral infarction) are explicitly excluded from risk adjustment scoring. This does not mean the code is clinically unimportant — it remains essential for functional status documentation, post-acute care authorization, and accurate severity of illness capture. Organizations participating in value-based care contracts should still capture this diagnosis to reflect true patient complexity in quality metrics. Annual recapture requirements do not apply since there is no RAF attached, but clinical completeness audits will still flag its absence when OT or neuropsych documentation clearly supports the diagnosis.^5,6

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🏥 MS-DRG Assignment

Scenario	Principal Dx	Secondary Dx	MS-DRG	MDC
Acute rehab admission for post-stroke deficits	I69.312	I69.351 (hemiplegia)	DRG 056 or 057 — Degenerative Nervous System Disorders ± MCC	MDC 01
Acute stroke admission (CI principal)	I63.411 (acute CI)	I69.312 (not appropriate here — use at subsequent encounter)	DRG 065/066 — Intracranial Hemorrhage or Cerebral Infarction	MDC 01
SNF/LTPAC assessment encounter	I69.312	Additional sequelae	DRG 056/057 or 083/084/085 depending on full DX profile	MDC 01

ICD-10 CM I69.312 is a non-CC, non-MCC code, meaning it does not independently shift the DRG tier when listed as a secondary diagnosis. The primary DRG driver in post-stroke inpatient admissions will be the principal diagnosis and any CC/MCC secondary diagnoses (e.g., hemiplegia under I69.35x carries CC/MCC weight, pneumonia, UTI, etc.). When I69.312 is used as the principal diagnosis for an inpatient rehabilitation admission, the DRG assignment will fall into MDC 01 and be refined based on the presence or absence of MCCs in the secondary diagnosis list. Coders must ensure they are not assigning I69.312 during the acute stroke inpatient stay — it is a sequela code applicable only to subsequent encounters after the acute infarction episode. Missequencing I69.312 as a principal during the acute stay is a documented auditor target and can trigger DRG reassignment or claim denial.^1,2

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🔗 Related ICD-10-CM Codes

Other Cognitive Sequelae of Cerebral Infarction (I69.31x Family):

• I69.310 — Attention and concentration deficit following cerebral infarction
• I69.311 — Memory deficit following cerebral infarction
• I69.313 — Psychomotor deficit following cerebral infarction
• I69.314 — Frontal lobe and executive function deficit following cerebral infarction
• I69.315 — Cognitive social or emotional deficit following cerebral infarction
• I69.318 — Other symptoms and signs involving cognitive functions following cerebral infarction

Visuospatial Deficit in Other Cerebrovascular Sequelae:

• I69.012 — Visuospatial deficit and spatial neglect following nontraumatic subarachnoid hemorrhage
• I69.112 — Visuospatial deficit and spatial neglect following nontraumatic intracerebral hemorrhage
• I69.812 — Visuospatial deficit and spatial neglect following other cerebrovascular disease
• I69.912 — Visuospatial deficit and spatial neglect following unspecified cerebrovascular disease
• H53.4x — Visual field defects (separately codeable when true visual field loss is also present, distinct from neglect)

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🛠️ Commonly Associated CPT Codes

• 97530 — Therapeutic activities, each 15 minutes: Occupational therapy using therapeutic activities to address spatial neglect and visuospatial deficits is commonly billed alongside I69.312; supports prism adaptation therapy, scanning training, and ADL retraining in the neglect-impaired patient.⁷
• 97129/97130 — Therapeutic interventions that focus on cognitive function: Codes for cognitive function intervention, direct (97129, first 15 min) and each additional 15 min (97130) are appropriate when the OT or SLP is directly addressing visuospatial processing deficits; I69.312 serves as a primary supporting diagnosis for medical necessity.⁷
• 96116 — Neurobehavioral status exam, clinical assessment: Neuropsychological testing encounters that document spatial neglect and visuospatial deficits can be supported by I69.312; coders should verify that the provider links findings back to the prior infarction.⁷
• 97535 — Self-care/home management training, each 15 min: Dressing apraxia and ADL training targeting spatial neglect sequelae are billed under this CPT; frequently paired with I69.312 in inpatient rehab and outpatient OT settings.⁷
• 92065 — Orthoptic and/or pleoptic training: When vision therapy or prism-based neglect rehabilitation is employed, this CPT may apply; confirm payer coverage as prior authorization is commonly required when I69.312 is the supporting diagnosis.⁷

NCCI Bundling Considerations

When billing therapeutic CPT codes (97530, 97129, 97535) alongside evaluation/management codes on the same date of service, NCCI bundling rules require that distinct, separately identifiable services are documented to support unbundling with a -59 modifier. Neuropsychological testing codes (96116, 96132, 96133) are not typically bundled with therapeutic intervention codes, but same-day billing of evaluation and re-evaluation codes without documented distinct clinical purpose will trigger NCCI edits. Always verify that the procedure note specifies the focus of each timed service when multiple codes are submitted with I69.312 as the supporting diagnosis.^1,2

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🔬 ICD-10-PCS Crosswalk

• GZ3ZZZZ — Psychological Tests, no qualifier: When neuropsychological assessment of visuospatial function is performed in the inpatient setting, this ICD-10-PCS code from the Mental Health section may be applicable to capture the procedure; supports the I69.312 diagnosis for inpatient DRG purposes.¹
• F07Z6EZ — Speech Treatment, Attention Process Training: In inpatient rehabilitation settings, cognitive attention training targeting spatial neglect may be captured under PCS rehabilitation codes in Section F; coders should confirm the specific modality documented by the treating therapist.¹
• F06Z6EZ — Speech Assessment involving attention processing: If a speech-language pathologist performs a cognitive-communication assessment that includes spatial attention components in the inpatient setting, this PCS code may support the clinical picture alongside I69.312.¹

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💊 Coding Scenarios and Examples

Scenario 1: Post-Stroke Rehab Admission with Spatial Neglect

A 68-year-old male is admitted to an acute inpatient rehabilitation facility 3 weeks after discharge from the hospital following a right MCA territory cerebral infarction. OT evaluation documents left hemispatial neglect — patient consistently fails to eat food on the left side of his tray, bumps into objects on his left, and shows significant left-side omissions on cancellation tasks. Neuropsychology confirms visuospatial deficit and spatial neglect causally linked to the prior infarction. He also has residual left hemiplegia of the dominant upper extremity.

Correct Coding:

• I69.312 — Visuospatial deficit and spatial neglect following cerebral infarction (principal)
• I69.351 — Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (secondary)

Sequencing: I69.312 is appropriate as principal for this rehab admission since it is the primary reason for the rehabilitation stay; hemiplegia is added as a secondary diagnosis. CDI Note: Confirm that the provider explicitly links both deficits to the prior infarction in the H&P or admission note — implied causation is insufficient per ICD-10-CM guidelines.^1,2

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Scenario 2: Outpatient Neurology Follow-Up

A 74-year-old female presents to her neurologist 6 months post-cerebral infarction. She reports difficulty navigating her home and has been found wandering. Neurological exam confirms persistent visuospatial deficit and topographic disorientation linked to the prior CI. The neurologist also documents mild expressive dysphasia.

Correct Coding:

• I69.312 — Visuospatial deficit and spatial neglect following cerebral infarction
• I69.321 — Dysphasia following cerebral infarction

Sequencing: Sequence the primary reason for the visit first (I69.312 per provider documentation); I69.321 is added as an additional code since both sequelae are addressed. Do not add Z86.73 — the presence of these residual deficits makes Z86.73 an Excludes 1 violation.^1,2

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Scenario 3: Inpatient Acute Stroke Admission — Sequela Code Misuse Prevention

A 61-year-old male is admitted via the ED with a new left hemisphere ischemic stroke (MCA territory, confirmed by MRI). Secondary review of history shows a prior right hemisphere infarction from 2 years ago with documented residual left-sided spatial neglect per outpatient records.

Correct Coding:

• I63.411 — Cerebral infarction due to embolism of right middle cerebral artery (principal — current acute event)
• I69.312 — Visuospatial deficit and spatial neglect following cerebral infarction (secondary — residual sequela from prior CI)

Sequencing: The new acute infarction is always sequenced as principal during the acute admission. I69.312 may be captured as a secondary diagnosis to reflect the pre-existing sequela from the prior infarction, as long as it is treated or monitored during this stay. CDI Note: Do not skip I69.312 on this encounter if the deficit is acknowledged and affects the plan of care — it contributes to severity of illness documentation even though it is non-CC/non-MCC.^1,2

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⚠️ Coding Pitfalls and Tips

1. Do not use I69.312 during the acute stroke inpatient admission as the principal diagnosis. This is a sequela code — it reflects a late effect that persists after the acute phase of the infarction has resolved. Using it as principal during the acute encounter will cause DRG misassignment and will likely be flagged by the MAC or RAC. The acute cerebral infarction (I63.x) must be the principal diagnosis during the index inpatient stay.^1,2

2. Never assign Z86.73 on the same claim as I69.312. This is an Excludes 1 relationship — they are mutually exclusive by definition. Z86.73 states there are NO residual deficits; I69.312 states there ARE residual deficits. Co-assignment triggers an NCCI edit and represents a fundamental logical contradiction in the medical record.^1,2

3. Spatial neglect ≠ visual field defect — code both if both are documented. Hemispatial neglect (I69.312) is an attentional disorder; visual field loss such as homonymous hemianopia (H53.46x) is an optic pathway deficit. They frequently co-occur after MCA infarction but are distinct conditions. If the provider documents both, both should be coded — they are not redundant.^3,4

4. Do not default to I69.30 (Unspecified sequelae) when I69.312 clearly applies. When neuropsychological testing, OT documentation, or provider notes explicitly identify visuospatial deficit or spatial neglect linked to a prior CI, I69.312 must be selected. Defaulting to I69.30 when a more specific code is available violates ICD-10-CM Official Guidelines on code specificity and may trigger downcoding on payer review.^1,2

5. CDI query is often needed to unlock this code. Attending physicians may document “post-stroke cognitive deficits” or “neurological sequelae” without specifying visuospatial or spatial neglect. When OT or neuropsychology notes clearly document spatial neglect findings, a CDI query asking the attending to specify the type of cognitive deficit and link it to the prior infarction is appropriate and should be routine in inpatient rehab and stroke follow-up units.²

6. This code does not generate HCC/RAF value — but don’t skip it. Even without risk adjustment credit, I69.312 contributes to accurate severity of illness documentation, supports medical necessity for inpatient rehabilitation admission, and strengthens the clinical record for quality metric reporting (e.g., stroke core measures, functional outcome tracking). Omitting it when supported by documentation is a completeness failure that will be flagged in CDI and coding quality audits.^5,6

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📚 Sources

1. Centers for Medicare & Medicaid Services (CMS) & National Center for Health Statistics (NCHS). *ICD-10-CM Official Guidelines for Coding and Reporting, FY2026.* U.S. Department of Health and Human Services; 2026. https://www.cms.gov/medicare/coding-billing/icd-10-codes 2. AAPC. *ICD-10-CM Code I69.312 — Visuospatial deficit and spatial neglect following cerebral infarction.* AAPC Coder; 2026. https://www.aapc.com/codes/icd-10-codes/I69.312 3. Heilman KM, Valenstein E, Watson RT. *Neglect and related disorders.* Semin Neurol. 2000;20(4):463–470. [Spatial neglect clinical framework] 4. Kerkhoff G. *Spatial hemineglect in humans.* Prog Neurobiol. 2001;63(1):1–27. [Visuospatial deficit and neglect pathophysiology] 5. Blue Cross NC. *HCC Risk Adjustment Coding Documentation Guide — ICD-10 Sequelae of Cerebrovascular Disease.* Blue Cross and Blue Shield of North Carolina; 2023. https://www.bluecrossnc.com/providers 6. CMS. *2026 Benefit Year Final HHS Risk Adjustment Model Coefficients.* Centers for Medicare & Medicaid Services; January 2025. https://www.cms.gov/files/document/2026-benefit-year-final-hhs-risk-adjustment-model-coefficients2025-01-13.pdf 7. American Medical Association. *CPT 2026 Professional Edition.* AMA Press; 2026. [CPT codes 97129, 97130, 97530, 97535, 96116, 92065]