ICD-10 Coding for Bilateral Carotid Stenosis(I65.23)
Complete ICD-10-CM coding and documentation guide for Bilateral Carotid Stenosis. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Bilateral Carotid Stenosis
I65.2-I65.29Primary Range
Occlusion and stenosis of carotid artery
This range includes codes for stenosis and occlusion of carotid arteries, specifying laterality and bilateral involvement.
Cerebral infarction due to carotid stenosis
This range is used when cerebral infarction is caused by carotid stenosis, requiring linkage between the stenosis and infarction.
Key Information: ICD-10 code for bilateral carotid stenosis
Essential facts and insights about Bilateral Carotid Stenosis
Primary ICD-10-CM Code for bilateral carotid stenosis
Decision Criteria
clinical Criteria
- Imaging shows bilateral stenosis >50%
documentation Criteria
- Explicit mention of 'bilateral' in clinical notes
Applicable To
- Bilateral carotid artery stenosis
- Bilateral carotid artery occlusion
Excludes
- Cerebral infarction due to carotid stenosis (I63.2-)
Clinical Validation Requirements
- Imaging confirmation of bilateral stenosis
- Documentation of stenosis severity (e.g., >50%)
Code-Specific Risks
- Assuming bilateral involvement without explicit documentation
- Not specifying laterality
Coding Notes
- Ensure documentation specifies 'bilateral' to use this code.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Cerebral infarction due to carotid stenosis
I63.2-Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Bilateral Carotid Stenosis to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code I65.23.
Impact
Clinical: Misrepresentation of patient condition., Regulatory: Potential audit issues., Financial: Incorrect DRG assignment affecting reimbursement.
Mitigation Strategy
Document causation clearly if infarction is due to stenosis.
Impact
Reimbursement: Incorrect coding can lead to denied claims., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Ensure documentation explicitly states 'bilateral' or 'both sides'.
Impact
Failure to document laterality can lead to incorrect coding.
Mitigation Strategy
Implement thorough documentation practices.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for Bilateral Carotid Stenosis, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Bilateral Carotid Stenosis
Use these documentation templates to ensure complete and accurate documentation for Bilateral Carotid Stenosis. These templates include all required elements for proper coding and billing.
Neurology Progress Note
Specialty: NeurologyRequired Elements
- Laterality
- Stenosis severity
- Imaging results
- Symptom correlation
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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