ICD-10 Coding for Carotid Artery Occlusion(I65.21, I65.22, I65.23, I65.29, I63.2-)
Complete ICD-10-CM coding and documentation guide for Carotid Artery Occlusion. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Carotid Artery Occlusion
I65.21-I65.29Primary Range
Occlusion and stenosis of carotid artery
This range covers occlusions and stenoses of the carotid artery, specifying laterality and presence of cerebral infarction.
Cerebral infarction due to carotid artery occlusion
Used when a cerebral infarction is caused by carotid artery occlusion.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| I65.21 | Occlusion and stenosis of right carotid artery | Use when there is documented occlusion or stenosis of the right carotid artery without cerebral infarction. |
|
| I65.22 | Occlusion and stenosis of left carotid artery | Use when there is documented occlusion or stenosis of the left carotid artery without cerebral infarction. |
|
| I65.23 | Occlusion and stenosis of bilateral carotid arteries | Use when there is documented occlusion or stenosis of both carotid arteries without cerebral infarction. |
|
| I65.29 | Occlusion and stenosis of unspecified carotid artery | Use when laterality is not specified in the documentation. |
|
| I63.2- | Cerebral infarction due to carotid artery occlusion | Use when a cerebral infarction is documented as resulting from carotid artery occlusion. |
|
Clinical Decision Support
Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.
Key Information: ICD-10 code for carotid artery occlusion
Essential facts and insights about Carotid Artery Occlusion
Primary ICD-10-CM Codes for carotid artery occlusion
Decision Criteria
clinical Criteria
- Confirmed occlusion or stenosis of the right carotid artery
Applicable To
- Right carotid artery occlusion
- Right carotid artery stenosis
Excludes
- Cerebral infarction due to carotid artery occlusion (I63.2-)
Clinical Validation Requirements
- Imaging showing occlusion or stenosis
- Clinical symptoms consistent with carotid artery disease
Code-Specific Risks
- Incorrect laterality documentation
- Failure to document degree of stenosis
Coding Notes
- Ensure laterality is documented clearly to avoid miscoding.
I65.22 - Occlusion and stenosis of left carotid artery
Use when there is documented occlusion or stenosis of the left carotid artery without cerebral infarction.
Applicable To
- Left carotid artery occlusion
- Left carotid artery stenosis
Excludes
- Cerebral infarction due to carotid artery occlusion (I63.2-)
Clinical Validation Requirements
- Imaging showing occlusion or stenosis
- Clinical symptoms consistent with carotid artery disease
Coding Notes
Ensure laterality is documented clearly to avoid miscoding.
I65.23 - Occlusion and stenosis of bilateral carotid arteries
Use when there is documented occlusion or stenosis of both carotid arteries without cerebral infarction.
Applicable To
- Bilateral carotid artery occlusion
- Bilateral carotid artery stenosis
Excludes
- Cerebral infarction due to carotid artery occlusion (I63.2-)
Clinical Validation Requirements
- Imaging showing occlusion or stenosis
- Clinical symptoms consistent with carotid artery disease
Coding Notes
Ensure laterality is documented clearly to avoid miscoding.
I65.29 - Occlusion and stenosis of unspecified carotid artery
Use when laterality is not specified in the documentation.
Applicable To
- Unspecified carotid artery occlusion
- Unspecified carotid artery stenosis
Excludes
- Cerebral infarction due to carotid artery occlusion (I63.2-)
Clinical Validation Requirements
- Imaging showing occlusion or stenosis
- Clinical symptoms consistent with carotid artery disease
Coding Notes
Encourage documentation of laterality to avoid using unspecified codes.
I63.2- - Cerebral infarction due to carotid artery occlusion
Use when a cerebral infarction is documented as resulting from carotid artery occlusion.
Applicable To
- Cerebral infarction due to carotid artery occlusion
Excludes
- Occlusion and stenosis of carotid artery without infarction (I65.2-)
Clinical Validation Requirements
- Imaging confirming cerebral infarction
- Clinical symptoms of stroke
Coding Notes
Ensure proper linkage between infarction and occlusion codes.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits
Z86.73Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Carotid Artery Occlusion to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code I65.21.
Impact
Clinical: May lead to inappropriate treatment decisions., Regulatory: Non-compliance with coding standards., Financial: Potential for reduced reimbursement.
Mitigation Strategy
Ensure clear documentation of causality in medical records., Use structured templates for stroke documentation.
Impact
Reimbursement: Incorrect coding can lead to reduced reimbursement., Compliance: May result in non-compliance with coding guidelines., Data Quality: Affects accuracy of clinical data and reporting.
Mitigation Strategy
Ensure documentation specifies occlusion to use I65.2- codes.
Impact
Inadequate documentation of laterality can lead to miscoding.
Mitigation Strategy
Implement mandatory fields for laterality in electronic health records.
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 Carotid Artery Occlusion, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Carotid Artery Occlusion
Use these documentation templates to ensure complete and accurate documentation for Carotid Artery Occlusion. These templates include all required elements for proper coding and billing.
Acute Stroke with Carotid Occlusion
Specialty: NeurologyRequired Elements
- Chief complaint
- Imaging findings
- Neurological exam
- Treatment plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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