ICD-10 Coding for Bilateral Carotid Artery Disease(I65.23, I63.231)
Complete ICD-10-CM coding and documentation guide for Bilateral Carotid Artery Disease. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Bilateral Carotid Artery Disease
I65-I66Primary Range
Occlusion and stenosis of cerebral arteries
This range includes codes for occlusion and stenosis of carotid arteries, which is directly relevant to bilateral carotid artery disease.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| I65.23 | Occlusion and stenosis of bilateral carotid arteries | Use when imaging confirms bilateral carotid artery stenosis or occlusion. |
|
| I63.231 | Cerebral infarction due to unspecified occlusion or stenosis of right carotid artery | Use when a cerebral infarction is documented as caused by 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 bilateral carotid artery disease
Essential facts and insights about Bilateral Carotid Artery Disease
Primary ICD-10-CM Codes for bilateral carotid artery disease
Decision Criteria
clinical Criteria
- Imaging shows ≥50% stenosis in symptomatic patients
documentation Criteria
- Explicit mention of bilateral involvement
Applicable To
- Bilateral carotid artery stenosis
- Bilateral carotid artery occlusion
Excludes
- Cerebral infarction due to carotid stenosis (I63.23-)
Clinical Validation Requirements
- Imaging confirmation of stenosis or occlusion
- Documentation of percentage stenosis
Code-Specific Risks
- Misclassification if laterality is not specified
- Incorrect use without imaging confirmation
Coding Notes
- Ensure documentation specifies laterality and degree of stenosis.
I63.231 - Cerebral infarction due to unspecified occlusion or stenosis of right carotid artery
Use when a cerebral infarction is documented as caused by carotid stenosis.
Clinical Validation Requirements
- Documentation of cerebral infarction
- Causal relationship with carotid stenosis
Coding Notes
Ensure causal relationship is 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)
Z86.73Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Bilateral Carotid Artery Disease to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code I65.23.
Impact
Clinical: Leads to incomplete clinical records., Regulatory: Non-compliance with documentation standards., Financial: Potential claim denials due to insufficient documentation.
Mitigation Strategy
Always document laterality in imaging reports., Review documentation for completeness before submission.
Impact
Reimbursement: May lead to denied claims if not supported by imaging., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate clinical data representation.
Mitigation Strategy
Ensure imaging confirms stenosis or occlusion before coding.
Impact
Lack of imaging confirmation for coded stenosis.
Mitigation Strategy
Require imaging reports before coding.
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 Bilateral Carotid Artery Disease, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Bilateral Carotid Artery Disease
Use these documentation templates to ensure complete and accurate documentation for Bilateral Carotid Artery Disease. These templates include all required elements for proper coding and billing.
Bilateral Carotid Stenosis with TIA
Specialty: NeurologyRequired Elements
- Patient history of TIA
- Imaging results
- Stenosis percentage
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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