ICD-10 Coding for Bilateral Carotid Artery Stenosis(I65.23)
Complete ICD-10-CM coding and documentation guide for Bilateral Carotid Artery Stenosis. 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 Stenosis
I65.2-I65.29Primary Range
Occlusion and stenosis of carotid artery
This range includes codes for stenosis of carotid arteries, specifying laterality and bilateral involvement.
Key Information: ICD-10 code for bilateral carotid artery stenosis
Essential facts and insights about Bilateral Carotid Artery Stenosis
Primary ICD-10-CM Code for bilateral carotid artery stenosis
Decision Criteria
clinical Criteria
- Bilateral stenosis confirmed by imaging
documentation Criteria
- Explicit mention of 'bilateral carotid artery stenosis' in records
Applicable To
- Bilateral carotid artery stenosis
Excludes
- Atherosclerosis of carotid arteries (I70.8)
Clinical Validation Requirements
- Doppler ultrasound showing PSV ≥230 cm/s bilaterally
- CTA/MRA indicating ≥70% stenosis in both carotids
Code-Specific Risks
- Incorrectly coding as unilateral or unspecified
- Omitting associated conditions like stroke
Coding Notes
- Ensure documentation specifies bilateral involvement and severity of stenosis.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
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 Bilateral Carotid Artery Stenosis to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code I65.23.
Impact
Clinical: May lead to inappropriate treatment decisions., Regulatory: Increases risk of audit and compliance issues., Financial: Potential for denied claims due to lack of specificity.
Mitigation Strategy
Educate clinicians on the importance of detailed documentation., Use templates that prompt for specific details.
Impact
Reimbursement: Incorrect coding can lead to reduced reimbursement., Compliance: May trigger audits for incorrect laterality coding., Data Quality: Affects accuracy of clinical data and reporting.
Mitigation Strategy
Use I65.23 when documentation confirms bilateral stenosis.
Impact
Incorrect coding of laterality can lead to audit findings.
Mitigation Strategy
Ensure documentation explicitly states laterality and severity.
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 Stenosis, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Bilateral Carotid Artery Stenosis
Use these documentation templates to ensure complete and accurate documentation for Bilateral Carotid Artery Stenosis. These templates include all required elements for proper coding and billing.
Bilateral carotid stenosis with TIA
Specialty: NeurologyRequired Elements
- History of present illness
- Imaging results
- Physical exam findings
- Treatment plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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