ICD-10 Coding for Stenosis of Carotid Artery(I65.21, I65.22, I65.23, I65.29)
Complete ICD-10-CM coding and documentation guide for Stenosis of Carotid Artery. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Stenosis of Carotid Artery
I65.2Primary Range
Occlusion and stenosis of carotid artery
This range includes codes specifically for stenosis of the carotid artery, differentiated by laterality and specification.
Cerebral infarction due to stenosis of precerebral arteries
Used when cerebral infarction is a result of carotid stenosis, requiring explicit linkage in documentation.
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 | Occlusion and stenosis of right carotid artery | Use when there is documented stenosis of the right carotid artery with specified percentage. |
|
| I65.22 | Occlusion and stenosis of left carotid artery | Use when there is documented stenosis of the left carotid artery with specified percentage. |
|
| I65.23 | Occlusion and stenosis of bilateral carotid arteries | Use when there is documented stenosis of both carotid arteries with specified percentage. |
|
| I65.29 | Occlusion and stenosis of unspecified carotid artery | Use when stenosis is documented but laterality is not specified. |
|
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 carotid artery stenosis
Essential facts and insights about Stenosis of Carotid Artery
Primary ICD-10-CM Codes for stenosis of carotid artery
Decision Criteria
clinical Criteria
- Presence of ≥50% stenosis in the right carotid artery confirmed by imaging.
Applicable To
- Nontraumatic dissection of right carotid artery
Excludes
- Traumatic dissection of carotid artery (S15.0)
Clinical Validation Requirements
- Imaging showing ≥50% stenosis of the right carotid artery
Code-Specific Risks
- Incorrect laterality documentation
Coding Notes
- Ensure laterality is clearly documented to avoid unspecified coding.
I65.22 - Occlusion and stenosis of left carotid artery
Use when there is documented stenosis of the left carotid artery with specified percentage.
Applicable To
- Nontraumatic dissection of left carotid artery
Excludes
- Traumatic dissection of carotid artery (S15.0)
Clinical Validation Requirements
- Imaging showing ≥50% stenosis of the left carotid artery
Coding Notes
Ensure laterality is clearly documented to avoid unspecified coding.
I65.23 - Occlusion and stenosis of bilateral carotid arteries
Use when there is documented stenosis of both carotid arteries with specified percentage.
Applicable To
- Nontraumatic dissection of bilateral carotid arteries
Excludes
- Traumatic dissection of carotid artery (S15.0)
Clinical Validation Requirements
- Imaging showing ≥50% stenosis in both carotid arteries
Coding Notes
Ensure bilateral involvement is clearly documented to avoid unspecified coding.
I65.29 - Occlusion and stenosis of unspecified carotid artery
Use when stenosis is documented but laterality is not specified.
Excludes
- Traumatic dissection of carotid artery (S15.0)
Clinical Validation Requirements
- Imaging showing stenosis of a carotid artery without specified laterality
Coding Notes
Document laterality to avoid using unspecified codes.
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 stenosis
I63.2-Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Stenosis of Carotid Artery 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 guidelines., Financial: Potential for denied claims due to unspecified coding.
Mitigation Strategy
Always document laterality in clinical notes., Use templates that prompt for laterality.
Impact
Reimbursement: May lead to incorrect billing and reimbursement issues., Compliance: Non-compliance with coding specificity requirements., Data Quality: Decreases accuracy of clinical data.
Mitigation Strategy
Query for specific stenosis percentage and laterality.
Impact
Failure to document laterality can lead to unspecified 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 Stenosis of Carotid Artery, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Stenosis of Carotid Artery
Use these documentation templates to ensure complete and accurate documentation for Stenosis of Carotid Artery. These templates include all required elements for proper coding and billing.
Bilateral Carotid Stenosis Evaluation
Specialty: NeurologyRequired Elements
- Patient symptoms
- Imaging results
- Stenosis percentage
- Laterality
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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