Last Updated on December 3, 2025 by Bilal Hasdemir

Carotid artery disease affects millions of Americans. Over 800,000 carotid endarterectomy procedures are done worldwide each year. This surgery is key to prevent strokes in those with severe carotid artery stenosis. Learn what is the icd 10 code for carotid endarterectomy. Understand the necessary billing and medical classification code clearly.

The ICD-10 coding system is important for medical billing and insurance for these surgeries. There’s no single ICD-10 code for carotid endarterectomy. But, codes like I65.21 for the right carotid artery and I65.22 for the left are used for occlusion and stenosis.

Getting the coding right is key for healthcare providers. It helps with getting paid and tracking these surgeries.

Key Takeaways

• Carotid endarterectomy is a big surgery for treating carotid artery disease.
• The ICD-10 coding system is key for medical billing and insurance.
• Related ICD-10 codes, like I65.21 and I65.22, describe carotid artery occlusion and stenosis.
• Accurate ICD-10 coding is vital for getting paid and tracking.
• Understanding ICD-10 codes for carotid endarterectomy is important for healthcare providers.

Understanding Carotid Endarterectomy

To code carotid endarterectomy correctly, you need to know what it is. It’s a surgery to clean out the carotid arteries. These arteries carry blood to the brain.

Definition and Medical Purpose

Carotid endarterectomy is a surgery to clear plaque from the carotid arteries. This improves blood flow to the brain and helps prevent strokes. It’s mainly done to treat carotid artery stenosis, where the arteries narrow due to plaque.

Clinical Indications for the Procedure

Doctors do carotid endarterectomy for a few reasons. It’s for people with symptoms like transient ischemic attacks or stroke. It’s also for those with significant narrowing of the arteries without symptoms.

The choice to do the surgery depends on how narrow the artery is, the patient’s health, and if they have symptoms.

Common Surgical Techniques and Approaches

There are two main ways to do carotid endarterectomy:

Conventional Endarterectomy

This traditional method involves opening the carotid artery to remove plaque. Then, the artery is closed, often with a patch to make it wider and improve blood flow.

Eversion Endarterectomy

In eversion endarterectomy, the carotid artery is turned inside out to remove plaque. This method might be less invasive and could lower the risk of some complications.

Knowing about carotid endarterectomy is key for accurate ICD-10 coding. The specific technique used affects the coding. By understanding the details of this surgery, coders can ensure accurate coding for it.

Overview of the ICD-10 Coding System

Healthcare professionals need to know the ICD-10 coding system well. It helps them document and bill for services like carotid endarterectomy. The ICD-10 system is more detailed than its predecessors, making coding more accurate.

Evolution from ICD-9 to ICD-10

The move from ICD-9 to ICD-10 was a big change. ICD-10 offers more detailed coding. This change was needed to keep up with modern medicine. The ICD-10 system helps track health trends better, improving care and billing.

Differences Between ICD-10-CM and ICD-10-PCS

ICD-10-CM and ICD-10-PCS have different roles. ICD-10-CM is for coding diagnoses, while ICD-10-PCS is for procedures in inpatient settings. ICD-10-PCS is key for carotid endarterectomy, helping with inpatient billing.

Structure and Components of ICD-10 Procedure Codes

ICD-10-PCS codes have several characters. Each character has its own meaning, important for correct coding.

Character Meanings in Procedural Coding

In ICD-10-PCS, each character in a code has a specific meaning. For example, “Open” might be used for carotid endarterectomy, showing it’s an open surgery.

To code accurately, healthcare providers must understand these components. Knowing how to use ICD-10 improves patient care and makes billing more efficient.

The ICD10 Code for Carotid Endarterectomy

The ICD-10-PCS code for carotid endarterectomy changes based on the surgical method. This surgery removes plaque from the carotid arteries to prevent strokes. The code is complex, influenced by the surgical technique and the arteries treated.

Primary ICD-10-PCS Codes for Carotid Endarterectomy

The main ICD-10-PCS codes for this surgery are in the Medical and Surgical Section. They are found in the “Arteries” body part group. The exact code depends on the approach, the artery treated, and if other procedures are done.

Breaking Down the Code Components

ICD-10-PCS codes use a character-based system. Each character represents a part of the procedure. For carotid endarterectomy, the key parts are:

• The root operation, which is “Extirpation” or “Removal,” meaning removing plaque or diseased tissue.
• The body part, which is the carotid artery.
• The approach, which can be open or percutaneous.
• Any additional devices or substances used, like a patch for angioplasty.

Code Variations Based on Surgical Approach

The surgical method greatly affects the ICD-10-PCS code for carotid endarterectomy.

Open Procedure Codes

For open carotid endarterectomy, the code is usually an “Open” approach. An example code for an open procedure might look like this:

Character	Description	Example Value
1	Section	Medical and Surgical
2	Body System	Arteries
3	Root Operation	Extirpation
4	Body Part	Carotid Artery
5	Approach	Open
6	Device	No Device
7	Qualifier	None

Percutaneous Procedure Codes

Percutaneous carotid endarterectomy accesses the artery through the skin, usually with a catheter. The coding for this method is different, with the “Approach” character being “Percutaneous.”

Understanding carotid endarterectomy and ICD-10-PCS coding is key for accurate billing. By knowing the code components and how they vary by surgical approach, healthcare providers can meet coding rules.

Related Diagnosis Codes for Carotid Procedures

Diagnosing carotid artery disease needs precise ICD-10-CM coding. This is key for both treating patients and handling administrative tasks. It affects how much patients pay and how doctors get paid.

ICD-10-CM Codes for Carotid Artery Stenosis

Carotid artery stenosis often needs surgery, like carotid endarterectomy. The right codes are vital for describing the condition. For example, I65.21 and I65.22 are for right and left carotid artery stenosis.

Codes for Carotid Artery Occlusion and Atherosclerosis

Atherosclerosis often leads to carotid artery stenosis and occlusion. The ICD-10-CM system has specific codes for these issues. For instance, I63.0- codes cover cerebral infarction due to thrombosis of precerebral arteries.

Coding for Symptomatic vs. Asymptomatic Carotid Disease

Whether a patient has symptoms or not affects the coding. Patients with symptoms, like TIAs or strokes, get different codes than those without. This shows how serious the condition is.

Stroke and TIA-Related Codes

Codes for strokes and TIAs are important for carotid procedures. For example, I63.- codes are for cerebral infarction, and G45.- codes are for TIAs. These codes help explain why carotid interventions are needed.

Condition	ICD-10-CM Code	Description
Right Carotid Artery Stenosis	I65.21	Occlusion and stenosis of right carotid artery
Left Carotid Artery Stenosis	I65.22	Occlusion and stenosis of left carotid artery
Cerebral Infarction	I63.-	Cerebral infarction due to various causes
Transient Cerebral Ischemic Attack	G45.-	Transient cerebral ischemic attacks

Knowing and using the right ICD-10-CM codes for carotid artery conditions is key. It helps with billing and understanding the disease better.

Coding Guidelines for Carotid Endarterectomy

To code carotid endarterectomy procedures right, you need to know the ICD-10-PCS guidelines well. These rules help ensure that doctors get paid right and follow coding laws.

Official ICD-10-PCS Coding Guidelines

The ICD-10-PCS coding system has a clear guide for coding carotid endarterectomy. It shows how to use ICD-10 procedure codes, stressing the need for detail and precision.

Key parts of ICD-10-PCS codes are:

• Section (character 1)
• Body system (character 2)
• Root operation (character 3)
• Body part (character 4)
• Approach (character 5)
• Device (character 6)
• Qualifier (character 7)

Procedure-Specific Coding Rules and Conventions

For carotid endarterectomy coding, you must know certain rules. For example, the root operation might be “Extirpation” or “Repair,” based on the procedure’s details.

Important coding rules include:

1. Choosing the right root operation for the procedure
2. Correctly identifying the body part (like the carotid artery)
3. Specifying the approach (open or endovascular)

Essential Documentation Requirements for Accurate Coding

Good coding needs detailed documentation. Operative reports are key for coders.

Operative Report Elements

A good operative report should have:

Element	Description	Importance
Procedure Details	What procedure was done	High
Anatomical Location	Where the procedure was done (e.g., left carotid artery)	High
Technique Used	How the surgery was done	Medium
Complications	Any issues during the surgery	High

By sticking to these guidelines and making sure operative reports are detailed, healthcare providers can code carotid endarterectomy procedures more accurately.

Modifiers and Additional Coding Considerations

Coding for carotid endarterectomy needs careful attention, focusing on modifiers and extra details. Modifiers add extra info about procedures. Getting them right is key for correct claim processing.

Coding for Bilateral vs. Unilateral Procedures

It’s important to know if a carotid endarterectomy is done on one side or both. The ICD-10-PCS system has different codes for each. For both sides, coders must report each procedure correctly.

For procedures on both sides, following ICD-10-PCS rules is vital. This might mean coding each procedure separately. Modifiers help tell if a procedure is on one side or both.

Patch Angioplasty and Shunt Placement Coding

Patch angioplasty and shunt placement are often part of carotid endarterectomy. It’s important to code these extra steps correctly. For example, using a patch to widen the artery after surgery needs its own code.

Procedure	ICD-10-PCS Code	Description
Carotid Endarterectomy with Patch Angioplasty	031T0ZZ	Extracranial Artery, Open Approach
Carotid Endarterectomy without Patch	031T0ZZ	Extracranial Artery, Open Approach
Shunt Placement during Carotid Endarterectomy	Additional code required	Dependent on specific procedure

Reporting Intraoperative Complications

Intraoperative complications change how you code carotid endarterectomy. Issues like bleeding or nerve injury need extra codes. This shows the procedure’s complexity.

Sequential Procedures During Same Operative Session

When doing multiple procedures in one session, like carotid endarterectomy and others, coding must be precise. The ICD-10-PCS has rules for these situations. It’s about the right order and using the right modifiers.

For example, if a patient has both sides done with patch angioplasty, each step must be coded right. Plus, any other procedures from that session.

Case Examples of Carotid Endarterectomy Coding

ICD-10 coding for carotid endarterectomy has specific rules. These rules are shown through real-life examples. These examples help doctors and coders know how to use the codes right.

Uncomplicated Right Carotid Endarterectomy

A 65-year-old patient had an uncomplicated right carotid endarterectomy. This surgery removes plaque from the right carotid artery to stop strokes. The ICD-10-PCS code for this is 03HT3ZZ. It stands for “Dilation of Right Common Carotid Artery, Percutaneous Approach.”

Procedure	ICD-10-PCS Code	Description
Right Carotid Endarterectomy	03HT3ZZ	Dilation of Right Common Carotid Artery, Percutaneous Approach

Carotid Endarterectomy with Patch Graft

A patient had a left carotid endarterectomy with a patch graft. The patch graft gets its own code, like 04L03JZ for “Bypass Left Common Carotid Artery to Left Internal Carotid Artery, Open Approach.” The main code for the endarterectomy is the same as before, but the patch graft gets its own.

Bilateral Carotid Endarterectomy Coding

For bilateral carotid endarterectomy, each side gets its own code. For example, if a patient has both sides done, the codes are 03HT3ZZ for the right and 03HT4ZZ for the left. This shows the procedure for each carotid artery.

Coding for Staged Procedures

When carotid endarterectomy is done in stages, each stage gets its own code. For instance, if the right side is done first and the left a week later, each gets its own ICD-10-PCS code. This depends on the specifics of the procedure and the artery involved.

Knowing these examples and using the right ICD-10 codes is key. It helps ensure accurate billing and payment for carotid endarterectomy procedures.

Reimbursement and Compliance Considerations

Healthcare providers need to know about reimbursement and compliance for carotid endarterectomy. This is important for managing their practice well. The procedure helps prevent strokes in patients with severe carotid artery stenosis. But, it comes with rules and financial issues to consider.

Medicare Guidelines for Carotid Procedures

Medicare has rules for paying for carotid endarterectomy. They require medical necessity documentation to justify the surgery. Providers must keep detailed records of the patient’s condition and symptoms.

Private Payer Policies and Coverage Determinations

Private insurance companies have their own rules for carotid endarterectomy. These can be different from Medicare’s. It’s key for providers to know each payer’s specific needs. They must pay attention to pre-authorization and coverage limitations.

Audit Risk Areas and Compliance Strategies

Carotid endarterectomy coding and billing face audit risks. This is due to incomplete or wrong documentation. Providers should use strong compliance strategies, like audits and staff training. Accurate ICD-10 coding and detailed records are essential.

Medical Necessity Documentation

Documenting medical necessity is vital for carotid endarterectomy compliance. This means recording symptoms, diagnostic results, and the procedure’s reason.

Understanding and following these guidelines helps healthcare providers manage carotid endarterectomy well. This ensures both financial success and follows the rules.

Conclusion

Accurate ICD-10 coding for carotid endarterectomy is key for medical billing and following rules. This article has given a detailed look at the ICD-10 coding for this procedure. It covers the main ICD-10-PCS codes, what each part means, and how different surgical methods affect the codes.

Knowing the ICD-10 coding system well is vital for healthcare providers. It helps them code correctly and get paid right. We talked about the rules for coding carotid endarterectomy, including official guidelines and special coding rules for this procedure.

In short, understanding carotid endarterectomy ICD-10 codes is important. It includes knowing the main codes, like 031T0ZZ, and the need for precise documentation. ICD-10 coding for carotid endarterectomy requires knowing the rules and following them. By doing this, healthcare providers can code accurately and get the best payment for their work.

FAQ

References

World Health Organization. Evidence-Based Medical Insight. Retrieved from https://icd.who.int/browse10/2019/en#/I65