ICD-10 Coding for Right ICA Stenosis(I65.21)
Complete ICD-10-CM coding and documentation guide for Right ICA Stenosis. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Right ICA Stenosis
Key Information: ICD-10 code for right ICA stenosis
Essential facts and insights about Right ICA Stenosis
Primary ICD-10-CM Code for right ica stenosis
Decision Criteria
clinical Criteria
- Documented stenosis without infarction
Applicable To
- Right ICA stenosis without cerebral infarction
Excludes
- Cerebral infarction due to stenosis (I63.23-)
Clinical Validation Requirements
- Doppler ultrasound showing PSV ≥125 cm/s
- Imaging confirming stenosis percentage
Code-Specific Risks
- Incorrectly linking to cerebral infarction without documentation
Coding Notes
- Ensure laterality and stenosis percentage are documented.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Personal history of transient ischemic attack (TIA)
Z86.73Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Cerebral infarction due to right carotid stenosis
I63.231Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Right ICA 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: Ambiguity in treatment planning., Regulatory: Potential non-compliance with coding standards., Financial: Reduced reimbursement due to unspecified codes.
Mitigation Strategy
Always document the affected side, Use templates that prompt laterality
Impact
Reimbursement: Incorrect coding may lead to claim denials., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Use I63.23- series for infarction due to stenosis.
Impact
Lack of imaging details can lead to audit flags.
Mitigation Strategy
Ensure all imaging reports are attached to patient 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 Right ICA Stenosis, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Right ICA Stenosis
Use these documentation templates to ensure complete and accurate documentation for Right ICA Stenosis. These templates include all required elements for proper coding and billing.
Right ICA Stenosis with TIA
Specialty: NeurologyRequired Elements
- Stenosis percentage
- Imaging results
- Symptom correlation
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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