ICD-10 Coding for Carotid Vascular Disease(I65.21, I65.22, I65.23)
Complete ICD-10-CM coding and documentation guide for Carotid Vascular Disease. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Carotid Vascular Disease
I65.2-I65.29Primary Range
Occlusion and stenosis of carotid artery
This range includes codes for specific stenosis or occlusion of the carotid arteries, which are critical for accurate diagnosis and treatment documentation.
Atherosclerosis of unspecified type of artery
These codes are used when atherosclerosis is the underlying cause of carotid artery disease.
Disorder of arteries and arterioles, unspecified
Used when documentation is insufficient to specify stenosis or 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 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. |
|
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 vascular disease
Essential facts and insights about Carotid Vascular Disease
Primary ICD-10-CM Codes for carotid vascular disease
Decision Criteria
clinical Criteria
- Presence of ≥50% stenosis in the right carotid artery
documentation Criteria
- Specific mention of right carotid stenosis or occlusion
Applicable To
- Right carotid artery stenosis
- Right carotid artery occlusion
Excludes
- Atherosclerosis of carotid artery (I70.91)
Clinical Validation Requirements
- Doppler ultrasound showing ≥50% stenosis
- CTA/MRA confirming narrowing
Code-Specific Risks
- Incorrect use if laterality is not specified
- Missing linkage to atherosclerosis if present
Coding Notes
- Ensure laterality is documented; link to atherosclerosis if applicable.
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
- Atherosclerosis of carotid artery (I70.92)
Clinical Validation Requirements
- Doppler ultrasound showing ≥50% stenosis
- CTA/MRA confirming narrowing
Coding Notes
Ensure laterality is documented; link to atherosclerosis if applicable.
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
- Atherosclerosis of carotid artery (I70.93)
Clinical Validation Requirements
- Doppler ultrasound showing ≥50% stenosis bilaterally
- CTA/MRA confirming bilateral narrowing
Coding Notes
Ensure bilateral involvement is documented; link to atherosclerosis if applicable.
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
Z86.73Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Carotid Vascular 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: Potential misdiagnosis or inappropriate treatment., Regulatory: Non-compliance with documentation standards., Financial: Reduced reimbursement due to unspecified coding.
Mitigation Strategy
Educate clinicians on documentation specificity, Use templates to guide documentation
Impact
Reimbursement: Lower reimbursement due to unspecified coding., Compliance: Non-compliance with coding specificity requirements., Data Quality: Decreased data quality and accuracy.
Mitigation Strategy
Ensure documentation specifies stenosis or occlusion to use I65.2- codes.
Impact
Lack of specific documentation for carotid stenosis can lead to audit findings.
Mitigation Strategy
Implement documentation templates and clinician education.
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 Vascular Disease, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Carotid Vascular Disease
Use these documentation templates to ensure complete and accurate documentation for Carotid Vascular Disease. These templates include all required elements for proper coding and billing.
Symptomatic Carotid Stenosis
Specialty: NeurologyRequired Elements
- History of symptoms
- Physical exam findings
- Imaging results
- Assessment and plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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