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ICD-10 Coding for Carotid Endarterectomy(I65.21, I65.22)

Complete ICD-10-CM coding and documentation guide for Carotid Endarterectomy. Includes clinical validation requirements, documentation requirements, and coding pitfalls.

Also known as:

CEACarotid Artery Surgery

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Related ICD-10 Code Ranges

Complete code families applicable to Carotid Endarterectomy

I65-I77Primary Range

Diseases of arteries, arterioles, and capillaries

This range includes codes for occlusion and stenosis of carotid arteries, which are directly relevant to carotid endarterectomy procedures.

03CL-03CM

ICD-10-PCS codes for procedures on the carotid arteries

This range includes procedural codes for carotid endarterectomy, specifying the approach and body part.

Code Comparison: When to Use Each Code

Compare key differences between these codes to ensure accurate selection

CodeDescriptionWhen to UseKey Documentation
I65.21Occlusion and stenosis of right carotid arteryUse when there is documented occlusion or stenosis of the right carotid artery requiring intervention.
  • Documented stenosis percentage using NASCET criteria
  • Symptom status with date of last neurological event
I65.22Occlusion and stenosis of left carotid arteryUse when there is documented occlusion or stenosis of the left carotid artery requiring intervention.
  • Documented stenosis percentage using NASCET criteria
  • Symptom status with date of last neurological event

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 endarterectomy

Essential facts and insights about Carotid Endarterectomy

The ICD-10 code for carotid endarterectomy is I65.21 for the right carotid artery and I65.22 for the left carotid artery.

Primary ICD-10-CM Codes for carotid endarterectomy

I65.21
Occlusion and stenosis of right carotid artery
Billable Code

Decision Criteria

clinical Criteria

  • Stenosis ≥70% for symptomatic or ≥80% for asymptomatic cases

documentation Criteria

  • Include imaging reports confirming stenosis

Applicable To

  • Right carotid artery stenosis
  • Right carotid artery occlusion

Excludes

  • Cerebral infarction due to carotid artery stenosis (I63.2)

Clinical Validation Requirements

  • Documented stenosis percentage using NASCET criteria
  • Symptom status with date of last neurological event

Code-Specific Risks

  • Incorrect use if stenosis percentage is not documented
  • Misclassification if symptom status is not clear

Coding Notes

  • Ensure documentation specifies the side and severity of stenosis.
View Full Code Details

Ancillary Codes

Additional codes that should be used in conjunction with the main diagnosis codes when applicable.

Presence of aortocoronary bypass graft

Z95.1
Use when there is concurrent coronary artery disease impacting surgical risk.

Differential Codes

Alternative codes to consider when ruling out similar conditions to the primary diagnosis.

Disorder of arteries, unspecified

I77.9
Use I77.9 when documentation lacks specificity about stenosis or occlusion.

Documentation & Coding Risks

Avoid these common documentation and coding issues when documenting Carotid Endarterectomy to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code I65.21.

Impact

Clinical: Inaccurate assessment of symptom status., Regulatory: Non-compliance with coding guidelines., Financial: Potential downcoding and reimbursement loss.

Mitigation Strategy

Implement EHR prompts for symptom documentation, Regular training on documentation requirements

Impact

Reimbursement: May lead to lower reimbursement rates., Compliance: Non-compliance with specificity requirements., Data Quality: Decreases accuracy of clinical data.

Mitigation Strategy

Ensure documentation specifies stenosis or occlusion with percentage.

Impact

Lack of documented symptom status can lead to audit findings.

Mitigation Strategy

Ensure all operative notes include symptom status and dates.

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 Endarterectomy, with expert answers to help guide accurate code selection and documentation.

Documentation Templates for Carotid Endarterectomy

Use these documentation templates to ensure complete and accurate documentation for Carotid Endarterectomy. These templates include all required elements for proper coding and billing.

Operative Note for Carotid Endarterectomy

Specialty: Vascular Surgery

Required Elements

  • Approach (open vs. percutaneous)
  • Vessel segments involved
  • Closure method
  • Intraoperative confirmation of result

Examples: Poor vs. Good Documentation

Poor Documentation Example
Performed right carotid endarterectomy.
Good Documentation Example
Open thromboendarterectomy of right common carotid artery via vertical neck incision. Continuous lesion extending from distal common carotid to proximal internal carotid. Atherosclerotic plaque removed en bloc. Primary closure performed. Intraoperative duplex confirmed <30% residual stenosis. Patient tolerated procedure well.
Explanation
The good example provides detailed procedural information, including approach, vessel segments, and intraoperative results.

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