ICD-10 Coding for Carotid Artery Stenosis(I65.21, I65.22, I65.23, I65.29, I63.0)
Complete ICD-10-CM coding and documentation guide for Carotid Artery Stenosis. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Carotid Artery Stenosis
I65.21-I65.29Primary Range
Occlusion and stenosis of carotid artery
This range covers the specific codes for carotid artery stenosis, including laterality and unspecified cases.
Cerebral infarction due to carotid stenosis
This range is used when carotid stenosis leads to a cerebral infarction.
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 stenosis is confirmed on the right carotid artery. |
|
| I65.22 | Occlusion and stenosis of left carotid artery | Use when stenosis is confirmed on the left carotid artery. |
|
| I65.23 | Occlusion and stenosis of bilateral carotid arteries | Use when stenosis is confirmed bilaterally. |
|
| I65.29 | Occlusion and stenosis of unspecified carotid artery | Use when laterality is not documented. |
|
| I63.0 | Cerebral infarction due to thrombosis of precerebral arteries | Use when infarction is directly linked to carotid stenosis. |
|
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 right carotid artery stenosis
Essential facts and insights about Carotid Artery Stenosis
Primary ICD-10-CM Codes for carotid artery stenosis
Decision Criteria
clinical Criteria
- Right carotid artery stenosis confirmed by imaging
Applicable To
- Nontraumatic dissection causing stenosis
Excludes
- Traumatic dissection of carotid artery
Clinical Validation Requirements
- Imaging showing stenosis percentage
- Laterality specified
Code-Specific Risks
- Incorrect laterality documentation
Coding Notes
- Ensure laterality is documented.
I65.22 - Occlusion and stenosis of left carotid artery
Use when stenosis is confirmed on the left carotid artery.
Applicable To
- Nontraumatic dissection causing stenosis
Excludes
- Traumatic dissection of carotid artery
Clinical Validation Requirements
- Imaging showing stenosis percentage
- Laterality specified
Coding Notes
Ensure laterality is documented.
I65.23 - Occlusion and stenosis of bilateral carotid arteries
Use when stenosis is confirmed bilaterally.
Applicable To
- Bilateral carotid stenosis
Excludes
- Traumatic dissection of carotid artery
Clinical Validation Requirements
- Imaging showing stenosis percentage on both sides
Coding Notes
Document bilateral stenosis clearly.
I65.29 - Occlusion and stenosis of unspecified carotid artery
Use when laterality is not documented.
Applicable To
- Unspecified laterality
Excludes
- Traumatic dissection of carotid artery
Clinical Validation Requirements
- Imaging available but laterality not specified
Coding Notes
Query for laterality if possible.
I63.0 - Cerebral infarction due to thrombosis of precerebral arteries
Use when infarction is directly linked to carotid stenosis.
Applicable To
- Infarction due to carotid stenosis
Excludes
- Infarction due to embolism
Clinical Validation Requirements
- Documentation of cerebral infarction linked to carotid stenosis
Coding Notes
Ensure clear linkage between stenosis and infarction.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Carotid Artery Stenosis to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code I65.21.
Impact
Clinical: Leads to inappropriate treatment decisions., Regulatory: Fails to meet coding standards., Financial: Potential for denied claims.
Mitigation Strategy
Train staff on documentation standards, Use templates that prompt for specific details
Impact
Reimbursement: May lead to incorrect reimbursement rates., Compliance: Non-compliance with coding standards., Data Quality: Decreases accuracy of clinical data.
Mitigation Strategy
Always document and code for laterality when available.
Impact
Reimbursement: Incorrect DRG assignment., Compliance: Potential audit risk., Data Quality: Misrepresentation of patient condition.
Mitigation Strategy
Ensure documentation clearly links stenosis to infarction.
Impact
Failure to document laterality can lead to incorrect coding.
Mitigation Strategy
Implement mandatory fields in EHR for laterality.
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 Stenosis, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Carotid Artery Stenosis
Use these documentation templates to ensure complete and accurate documentation for Carotid Artery Stenosis. These templates include all required elements for proper coding and billing.
Asymptomatic carotid stenosis
Specialty: NeurologyRequired Elements
- Patient history
- Imaging results
- Stenosis percentage
- Management plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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