ICD-10 Coding for Carotid Disease(I65.21, I65.22, I65.23, I77.9)
Complete ICD-10-CM coding and documentation guide for Carotid Disease. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Carotid Disease
I65.21-I65.29Primary Range
Occlusion and stenosis of carotid artery
This range covers specific codes for carotid artery stenosis, including laterality and severity.
Disorder of arteries and arterioles, unspecified
Used when the documentation is vague and does not specify stenosis or occlusion.
Atherosclerosis of other arteries
Used when atherosclerosis is confirmed as the cause of carotid stenosis.
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 stenosis or occlusion of the right carotid artery. |
|
| I65.22 | Occlusion and stenosis of left carotid artery | Use when there is documented stenosis or occlusion of the left carotid artery. |
|
| I65.23 | Occlusion and stenosis of bilateral carotid arteries | Use when there is documented stenosis or occlusion of both carotid arteries. |
|
| I77.9 | Disorder of arteries and arterioles, unspecified | Use when documentation is vague and does not specify stenosis or 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 stenosis
Essential facts and insights about Carotid Disease
Primary ICD-10-CM Codes for carotid disease
Decision Criteria
clinical Criteria
- Documented stenosis of right carotid artery with imaging confirmation.
Applicable To
- Right carotid artery stenosis
- Right carotid artery occlusion
Excludes
- Carotid artery dissection (I77.71)
Clinical Validation Requirements
- Duplex ultrasound showing ≥50% narrowing
- CTA/MRA confirming stenosis
Code-Specific Risks
- Incorrect laterality documentation
- Missing imaging confirmation
Coding Notes
- Ensure laterality is clearly documented.
I65.22 - Occlusion and stenosis of left carotid artery
Use when there is documented stenosis or occlusion of the left carotid artery.
Applicable To
- Left carotid artery stenosis
- Left carotid artery occlusion
Excludes
- Carotid artery dissection (I77.71)
Clinical Validation Requirements
- Duplex ultrasound showing ≥50% narrowing
- CTA/MRA confirming stenosis
Coding Notes
Ensure laterality is clearly documented.
I65.23 - Occlusion and stenosis of bilateral carotid arteries
Use when there is documented stenosis or occlusion of both carotid arteries.
Applicable To
- Bilateral carotid artery stenosis
- Bilateral carotid artery occlusion
Excludes
- Carotid artery dissection (I77.71)
Clinical Validation Requirements
- Duplex ultrasound showing ≥50% narrowing bilaterally
- CTA/MRA confirming bilateral stenosis
Coding Notes
Ensure bilateral involvement is clearly documented.
I77.9 - Disorder of arteries and arterioles, unspecified
Use when documentation is vague and does not specify stenosis or occlusion.
Applicable To
- Unspecified arterial disorder
Excludes
- Specific stenosis or occlusion codes
Clinical Validation Requirements
- Lack of specific documentation for stenosis or occlusion
Coding Notes
Query for specificity if possible.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Atherosclerosis of other arteries
I70.8Differential 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 Disease 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 denied claims or reduced reimbursement.
Mitigation Strategy
Train staff on documentation requirements., Use templates to ensure completeness.
Impact
Reimbursement: May lead to lower reimbursement due to lack of specificity., Compliance: Non-compliance with coding guidelines requiring specificity., Data Quality: Decreases data quality and accuracy in patient records.
Mitigation Strategy
Query for side: 'Is the stenosis left, right, or bilateral?'
Impact
Audits may focus on the specificity of documentation for carotid stenosis.
Mitigation Strategy
Ensure all documentation includes laterality, severity, and imaging confirmation.
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 Disease, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Carotid Disease
Use these documentation templates to ensure complete and accurate documentation for Carotid Disease. These templates include all required elements for proper coding and billing.
Neurology Progress Note
Specialty: NeurologyRequired Elements
- Patient symptoms
- Imaging results
- Stenosis percentage
- Etiology
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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