ICD-10 Coding for Carotid Stenosis(I65.21, I65.22, I65.23, I63.231)
Complete ICD-10-CM coding and documentation guide for Carotid Stenosis. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Carotid Stenosis
I65.2-I65.29Primary Range
Occlusion and stenosis of carotid artery
This range covers various types of carotid artery stenosis, including unilateral and bilateral cases.
Cerebral infarction due to carotid artery stenosis
Used when a cerebral infarction is directly linked to 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 stenosis is confirmed in the right carotid artery without cerebral infarction. |
|
| I65.22 | Occlusion and stenosis of left carotid artery | Use when stenosis is confirmed in the left carotid artery without cerebral infarction. |
|
| I65.23 | Occlusion and stenosis of bilateral carotid arteries | Use when stenosis is confirmed in both carotid arteries without cerebral infarction. |
|
| I63.231 | Cerebral infarction due to stenosis of right carotid artery | Use when a cerebral infarction is directly linked to right 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 carotid stenosis
Essential facts and insights about Carotid Stenosis
Primary ICD-10-CM Codes for carotid stenosis
Decision Criteria
clinical Criteria
- Presence of stenosis in the right carotid artery confirmed by imaging
documentation Criteria
- Documentation must specify 'right carotid artery stenosis'
Applicable To
- Right carotid artery stenosis
Excludes
- Cerebral infarction due to stenosis (I63.2-)
Clinical Validation Requirements
- Doppler ultrasound showing PSV ≥125 cm/s
- Angiography confirming stenosis ≥50%
Code-Specific Risks
- Misclassification if laterality is not specified
Coding Notes
- Ensure laterality is documented to avoid miscoding.
I65.22 - Occlusion and stenosis of left carotid artery
Use when stenosis is confirmed in the left carotid artery without cerebral infarction.
Applicable To
- Left carotid artery stenosis
Excludes
- Cerebral infarction due to stenosis (I63.2-)
Clinical Validation Requirements
- Doppler ultrasound showing PSV ≥125 cm/s
- Angiography confirming stenosis ≥50%
Coding Notes
Ensure laterality is documented to avoid miscoding.
I65.23 - Occlusion and stenosis of bilateral carotid arteries
Use when stenosis is confirmed in both carotid arteries without cerebral infarction.
Applicable To
- Bilateral carotid artery stenosis
Excludes
- Cerebral infarction due to stenosis (I63.2-)
Clinical Validation Requirements
- Doppler ultrasound showing bilateral PSV ≥125 cm/s
- Angiography confirming bilateral stenosis ≥50%
Coding Notes
Ensure bilateral involvement is documented to avoid miscoding.
I63.231 - Cerebral infarction due to stenosis of right carotid artery
Use when a cerebral infarction is directly linked to right carotid stenosis.
Applicable To
- Infarction due to right carotid stenosis
Clinical Validation Requirements
- Imaging confirming cerebral infarction
- Documentation linking infarction to right carotid stenosis
Coding Notes
Ensure causality between stenosis and infarction is documented.
Differential 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 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: May lead to inappropriate treatment decisions., Regulatory: Non-compliance with coding standards., Financial: Potential for denied claims.
Mitigation Strategy
Educate clinicians on the importance of specifying stenosis.
Impact
Reimbursement: Incorrect coding can lead to denied claims or incorrect reimbursement., Compliance: Failure to comply with coding guidelines may result in audits., Data Quality: Inaccurate data affects clinical decision-making and reporting.
Mitigation Strategy
Ensure documentation specifies whether the stenosis is on the right, left, or both sides.
Impact
Failure to document laterality can lead to incorrect coding.
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 Stenosis, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Carotid Stenosis
Use these documentation templates to ensure complete and accurate documentation for Carotid Stenosis. These templates include all required elements for proper coding and billing.
Asymptomatic carotid stenosis detected on screening
Specialty: NeurologyRequired Elements
- Patient demographics
- Imaging results
- Stenosis percentage
- Laterality
- Clinical findings
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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