2025 ICD-10-CM code I65.2
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Diseases of the circulatory system - Cerebrovascular diseases (I60-I69) Diseases of the circulatory system (I00-I99) Feed
Occlusion and stenosis of the carotid artery.
Modifiers may be applicable depending on the circumstances of the procedure (e.g., bilateral versus unilateral involvement).
Medical necessity for this code would be established by the presence of symptoms or findings indicative of carotid artery disease (e.g., TIA, stroke symptoms, bruit), confirmed by appropriate diagnostic imaging. The severity of the stenosis or occlusion should warrant intervention, either medical or surgical.
The clinical responsibility for this code would typically fall to a neurologist, vascular surgeon, or other physician specializing in cerebrovascular disease.The physician's role would involve diagnosis through imaging (e.g., carotid ultrasound, CT angiography, MRI), assessment of the severity of stenosis or occlusion, and determination of the appropriate treatment (e.g., medication, carotid endarterectomy, angioplasty with stenting).
In simple words: This code describes a blockage or narrowing of the carotid arteries in your neck, which supply blood to your brain.A blockage can reduce blood flow to the brain, potentially causing a stroke.
This code represents the complete or partial blockage (occlusion) and narrowing (stenosis) of one or both carotid arteries.The carotid arteries are major blood vessels in the neck that supply blood to the brain.Occlusion and stenosis can restrict blood flow to the brain, potentially leading to stroke or other neurological complications. This code should be used when the occlusion or stenosis is affecting the precerebral portion of the carotid artery. If the occlusion is documented as being in the cerebral portion of the internal carotid, code I66.8 (Occlusion and stenosis of other cerebral artery) should be used instead.
Example 1: A 65-year-old male patient presents with transient ischemic attacks (TIAs). Carotid ultrasound reveals significant stenosis of the right carotid artery.Code I65.2 is assigned., A 72-year-old female patient undergoes a carotid angiogram revealing near-total occlusion of the left carotid artery.Code I65.2 is assigned.Further codes may be added based on the clinical presentation and treatment., A 58-year-old patient with a history of hypertension and smoking presents with symptoms suggestive of a stroke. Imaging studies show a significant stenosis of both carotid arteries. Code I65.2 is assigned, along with codes for hypertension and tobacco use.
Detailed medical history, including symptoms, risk factors (hypertension, diabetes, hyperlipidemia, smoking, family history), physical examination findings, and results of diagnostic imaging studies (e.g., carotid ultrasound, CT angiography, MRI) are crucial.Documentation should clearly indicate the location and severity of the occlusion or stenosis (percentage of stenosis), and whether it is unilateral or bilateral.Treatment plan and response to treatment should also be documented.
** This code is specifically for occlusion and stenosis of the precerebral portion of the carotid artery.If the occlusion is in the cerebral portion, a different code (I66.8) is appropriate.Always review the complete clinical documentation to ensure accurate code assignment.
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- Specialties:Vascular Surgery, Neurology, Cardiology
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