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“Chronic microvascular ischemic changes.”
“White matter hyperintensities.”

If you’ve reviewed enough inpatient charts (or care for elderly patients), you’ve seen these findings on CT heads or MRI brains.

But here’s the thing:

• I rarely see it in provider notes.

• I never hear anyone mention it.

• I don’t think I ever learned about it in residency.

So I went digging.

Searching for Answers

UpToDate? Nothing.
A PubMed search for “chronic microvascular ischemic changes”? One lonely result.

So I hit the 2025 “easy button” (OpenEvidence) and asked: “What are chronic microvascular ischemic changes, and how do they impact patients?”

That led me to the real term: Cerebral Small Vessel Disease (CSVD).
That search gave me 636 PubMed results. Jackpot.

What is cerebral small vessel disease (CSVD)?

After discussing with a neurologist and performing a literature search, in short:

• Long-standing injury and dysfunction of small blood vessels in the brain

• On MRI: shows up as white matter hyperintensities, lacunar infarcts, old microinfarcts

• The most common, chronic, and progressive vascular disease (per this review)

• Management: the usual suspects (control BP, diabetes, cholesterol, smoking, etc.)

• Outcomes: linked to progressive cognitive decline (45% of dementias), gait disturbance, increased risk of stroke (25% of ischemic strokes), and functional impairment.

That’s… much of the average inpatient population.

Why This Matters for Inpatient Care

If you care for hospitalized patients, you see this daily:

• Small metabolic shifts (UTI, dehydration, low sodium) tip these patients into encephalopathy

• They’re more prone to delirium (which results in longer length of stay and increased staffing needs)

• Falls are more likely

• Many need post-acute PT/OT

This condition is quietly driving resource use across hospitals - it’s not just an incidental finding. Yet it’s rarely documented. So, the question is: Does it matter (is it a CC/MCC)?

Coding of CSVD

It’s never easy, and there is no code for cerebral small vessel disease.
Nor for chronic microvascular ischemic changes.

So, that means a trip down encoder lane.

• “Cerebral small vessel disease” → I67.89, Other cerebrovascular disease

• “Microvascular ischemic changes” → I67.82, Cerebral ischemia (includes “chronic cerebral ischemia”)

And both of these ICD-10-CM codes? They’re CCs!

So, the good news: DRG methodology will reimburse for the resources needed to manage these patients.
Bad news: since it’s almost never documented, we aren’t giving ourselves credit.

The MEAT of CSVD

As many of you know, inpatient coders can’t code directly from radiology reports. It needs provider documentation. So, where’s the MEAT (Monitor, Evaluate, Assess, Treat)?

• Monitoring and treating blood pressure, diabetes, cholesterol, smoking

• Placing on delirium precautions

• Giving antiplatelets

• PT/OT consults for associated gait and functional decline

• Counseling families on cognitive and functional expectations as a result of this condition

  • Which sometimes may lead to palliative care or hospice discussions / consultations.

Since becoming more aware of this disease process and intentionally including it in my documentation, it has stayed front-of-mind and helped shape my patient conversations and influence my goals of care conversations. That has sometimes resulted in consulting palliative care, and in some cases even hospice. And with MyChart providing immediate access to notes, I’ve had family members directly ask about this new term (CSVD or chronic cerebral ischemia) which they’ve never seen before. Those questions naturally open the door to deeper counseling, expectation-setting, and care planning. All of that, of course, is part of managing this condition

But the key is that the condition, and how it’s being managed (including counseling), has to be documented. That’s the only way to show its impact on the current admission and to make sure we get credit for the work we’re doing.

The Takeaway

CSVD is under-recognized but has a huge impact on our inpatient population. It contributes to encephalopathies, delirium, falls, strokes, dementia, and functional decline… and yes, it codes as a CC.

But if it’s not documented, we don’t get credit for managing it.

So:

• Providers: watch for it on brain imaging, document it when present, and include the MEAT to show how it’s affecting the patient and your care. It will make your care more complete, and it’s certainly changed the way I approach my patients.

• CDI programs: make sure your providers know what CSVD is and why it matters. Use education, tech, whatever tools you’ve got to bring it front-of-mind.

That’s all for now. Got thoughts or comments? Share them on Linkedin!

Cheers,
Robert

Thank you to Neurologist Dr. Zachary Goodwin for reviewing, and Laura Samson, RN BSN CCDS for editing this newsletter!

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