ICD-10 Coding for Internal Carotid Artery Stenosis(I65.21, I65.22, I65.23, I66.8)
Complete ICD-10-CM coding and documentation guide for Internal 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 Internal Carotid Artery Stenosis
I65.2-I66.8Primary Range
Occlusion and stenosis of precerebral and cerebral arteries
This range includes codes for stenosis of the internal carotid artery, specifying laterality and location (cervical vs. intracranial).
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 | Stenosis of right carotid artery | Use when documentation specifies nontraumatic stenosis of the right internal carotid artery. |
|
| I65.22 | Stenosis of left carotid artery | Use when documentation specifies nontraumatic stenosis of the left internal carotid artery. |
|
| I65.23 | Stenosis of bilateral carotid arteries | Use when documentation specifies nontraumatic stenosis of both internal carotid arteries. |
|
| I66.8 | Stenosis of other cerebral arteries | Use when the stenosis is in the intracranial portion of the carotid artery. |
|
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 right internal carotid artery stenosis
Essential facts and insights about Internal Carotid Artery Stenosis
Primary ICD-10-CM Codes for internal carotid artery stenosis
Decision Criteria
clinical Criteria
- Presence of symptoms and PSV ≥180 cm/s
documentation Criteria
- Clear documentation of nontraumatic stenosis and laterality
Applicable To
- Nontraumatic stenosis of right internal carotid artery
Excludes
- Traumatic stenosis of right carotid artery
Clinical Validation Requirements
- PSV ≥180 cm/s on duplex ultrasound
- TIA or stroke symptoms
Code-Specific Risks
- Incorrect laterality documentation can lead to coding errors.
Coding Notes
- Ensure laterality is documented clearly to avoid unspecified coding.
I65.22 - Stenosis of left carotid artery
Use when documentation specifies nontraumatic stenosis of the left internal carotid artery.
Applicable To
- Nontraumatic stenosis of left internal carotid artery
Excludes
- Traumatic stenosis of left carotid artery
Clinical Validation Requirements
- PSV ≥180 cm/s on duplex ultrasound
- Asymptomatic with ≥50% stenosis on CTA/MRA
Coding Notes
Ensure laterality is documented clearly to avoid unspecified coding.
I65.23 - Stenosis of bilateral carotid arteries
Use when documentation specifies nontraumatic stenosis of both internal carotid arteries.
Applicable To
- Nontraumatic stenosis of bilateral internal carotid arteries
Excludes
- Traumatic stenosis of bilateral carotid arteries
Clinical Validation Requirements
- Bilateral PSV >230 cm/s
- Plaque ≥50% on imaging
Coding Notes
Ensure bilateral involvement is documented clearly to avoid unspecified coding.
I66.8 - Stenosis of other cerebral arteries
Use when the stenosis is in the intracranial portion of the carotid artery.
Applicable To
- Stenosis of intracranial portion of carotid artery
Excludes
- Stenosis of precerebral carotid artery
Clinical Validation Requirements
- Documentation of 'intracranial' or 'supraclinoid' segment involvement
Coding Notes
Ensure the location of stenosis is documented as intracranial.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Cerebral infarction due to stenosis of right carotid artery
I63.21Cerebral infarction due to stenosis of left carotid artery
I63.22Cerebral infarction due to stenosis of bilateral carotid arteries
I63.23Differential 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 Internal Carotid Artery 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 reduced reimbursement.
Mitigation Strategy
Use standardized documentation templates, Regular training on documentation requirements
Impact
Clinical: Inaccurate patient records., Regulatory: Increased audit risk., Financial: Loss of potential reimbursement.
Mitigation Strategy
Ensure thorough review of documentation before coding, Implement coding audits to catch errors
Impact
Reimbursement: May lead to lower reimbursement due to unspecified coding., Compliance: Non-compliance with coding guidelines., Data Quality: Decreases accuracy of patient records.
Mitigation Strategy
Query the provider for clarification on laterality.
Impact
Reimbursement: Incorrect DRG assignment affecting reimbursement., Compliance: Potential audit risk for incorrect coding., Data Quality: Inaccurate clinical data affecting patient care.
Mitigation Strategy
Ensure documentation specifies the anatomical location of stenosis.
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 Internal Carotid Artery Stenosis, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Internal Carotid Artery Stenosis
Use these documentation templates to ensure complete and accurate documentation for Internal Carotid Artery Stenosis. These templates include all required elements for proper coding and billing.
Documenting carotid stenosis in neurology
Specialty: NeurologyRequired Elements
- Laterality of stenosis
- Degree of stenosis
- Imaging findings
- Symptoms related to stenosis
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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