ICD-10 Coding for Vertebral Artery Stenosis(I65.01, I65.02, I65.03, I65.09)
Complete ICD-10-CM coding and documentation guide for Vertebral Artery Stenosis. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Vertebral Artery Stenosis
I65.0-I65.9Primary Range
Occlusion and stenosis of precerebral arteries
This range includes codes for stenosis and occlusion of the vertebral artery, with specific codes for laterality.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| I65.01 | Occlusion and stenosis of right vertebral artery | Use when imaging confirms stenosis of the right vertebral artery. |
|
| I65.02 | Occlusion and stenosis of left vertebral artery | Use when imaging confirms stenosis of the left vertebral artery. |
|
| I65.03 | Occlusion and stenosis of bilateral vertebral arteries | Use when imaging confirms stenosis of both vertebral arteries. |
|
| I65.09 | Occlusion and stenosis of unspecified vertebral artery | Use when laterality is not specified in the documentation. |
|
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 vertebral artery stenosis
Essential facts and insights about Vertebral Artery Stenosis
Primary ICD-10-CM Codes for vertebral artery stenosis
Decision Criteria
clinical Criteria
- Imaging shows right vertebral artery stenosis.
Applicable To
- Right vertebral artery stenosis
- Right vertebral artery occlusion
Excludes
- Cerebral infarction due to vertebral artery stenosis (I63.5)
Clinical Validation Requirements
- Imaging confirmation of stenosis
- Documentation of right laterality
Code-Specific Risks
- Incorrect laterality documentation
Coding Notes
- Ensure laterality is documented to avoid unspecified coding.
I65.02 - Occlusion and stenosis of left vertebral artery
Use when imaging confirms stenosis of the left vertebral artery.
Applicable To
- Left vertebral artery stenosis
- Left vertebral artery occlusion
Excludes
- Cerebral infarction due to vertebral artery stenosis (I63.5)
Clinical Validation Requirements
- Imaging confirmation of stenosis
- Documentation of left laterality
Coding Notes
Ensure laterality is documented to avoid unspecified coding.
I65.03 - Occlusion and stenosis of bilateral vertebral arteries
Use when imaging confirms stenosis of both vertebral arteries.
Applicable To
- Bilateral vertebral artery stenosis
- Bilateral vertebral artery occlusion
Excludes
- Cerebral infarction due to vertebral artery stenosis (I63.5)
Clinical Validation Requirements
- Imaging confirmation of stenosis
- Documentation of bilateral involvement
Coding Notes
Ensure bilateral involvement is documented to avoid unspecified coding.
I65.09 - Occlusion and stenosis of unspecified vertebral artery
Use when laterality is not specified in the documentation.
Applicable To
- Unspecified vertebral artery stenosis
- Unspecified vertebral artery occlusion
Excludes
- Cerebral infarction due to vertebral artery stenosis (I63.5)
Clinical Validation Requirements
- Imaging confirmation of stenosis
- Lack of laterality documentation
Coding Notes
Query for laterality if not documented to avoid unspecified coding.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Dizziness and giddiness
R42Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Cerebral infarction due to vertebral artery stenosis
I63.5Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Vertebral Artery Stenosis to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code I65.01.
Impact
Clinical: May lead to inappropriate treatment decisions., Regulatory: Non-compliance with coding specificity requirements., Financial: Potential for reduced reimbursement.
Mitigation Strategy
Ensure imaging reports specify laterality., Train staff on the importance of documenting laterality.
Impact
Reimbursement: May lead to reduced reimbursement due to lack of specificity., Compliance: Non-compliance with coding guidelines for specificity., Data Quality: Decreases the accuracy of health data.
Mitigation Strategy
Ensure laterality is coded if documented in the medical record.
Impact
High risk of audit if laterality is not documented for vertebral artery stenosis.
Mitigation Strategy
Implement mandatory laterality documentation in imaging reports.
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 Vertebral Artery Stenosis, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Vertebral Artery Stenosis
Use these documentation templates to ensure complete and accurate documentation for Vertebral Artery Stenosis. These templates include all required elements for proper coding and billing.
Acute presentation with vertigo
Specialty: NeurologyRequired Elements
- Patient symptoms
- Imaging findings
- Laterality of stenosis
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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