ICD-10 Coding for Right Carotid Stenosis(I65.21)
Complete ICD-10-CM coding and documentation guide for Right Carotid Stenosis. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Right Carotid Stenosis
I65.2-I65.29Primary Range
Occlusion and stenosis of precerebral arteries
This range includes codes for stenosis of the carotid arteries, specifically the right carotid artery.
Key Information: ICD-10 code for right carotid stenosis
Essential facts and insights about Right Carotid Stenosis
Primary ICD-10-CM Code for right carotid stenosis
Decision Criteria
clinical Criteria
- Imaging confirms ≥50% stenosis of the right carotid artery.
documentation Criteria
- Documentation explicitly mentions 'right carotid stenosis'.
Applicable To
- Right carotid artery stenosis
- Right carotid artery occlusion
Excludes
- Carotid artery dissection (S15.01-)
Clinical Validation Requirements
- Imaging report (Doppler/CTA/MRA) showing ≥50% stenosis
Code-Specific Risks
- Ensure laterality is specified to avoid using unspecified codes.
Coding Notes
- Ensure documentation specifies 'stenosis' and the right side.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Atherosclerosis of right carotid artery
I70.91Differential 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 Right 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 documentation specificity., Use templates that prompt for necessary details.
Impact
Reimbursement: Incorrect DRG assignment may affect reimbursement., Compliance: Non-compliance with coding guidelines., Data Quality: Decreased accuracy in clinical data.
Mitigation Strategy
Ensure to use I65.21 when right side is specified.
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 Right Carotid Stenosis, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Right Carotid Stenosis
Use these documentation templates to ensure complete and accurate documentation for Right Carotid Stenosis. These templates include all required elements for proper coding and billing.
Neurology Consultation
Specialty: NeurologyRequired Elements
- Symptoms
- Imaging findings
- Stenosis percentage
- Laterality
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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