ICD-10 Guide

Carotid Endarterectomy

ICD-10 Coding for Carotid Endarterectomy(I65.21, I65.22)

PRIMARY SPECIALTYVascular Surgery

COMPLEXITYHigh

LAST UPDATED09/15/2025

Sam Tuffun, PT, DPT

Physical Therapist | Medical Coding & Billing Contributor

Diagnosis Overview

What is Carotid Endarterectomy?

Essential facts and insights about Carotid Endarterectomy

Key Clinical Considerations:

Transient ischemic attack (TIA) or stroke symptoms
Carotid duplex ultrasound showing significant stenosis (≥70%)
Bruit on auscultation of the carotid artery

Clinical Information

Clinical Criteria & Documentation Requirements

Patient history of cerebrovascular events
Results of imaging studies (ultrasound, CT, MRI)
Indication for surgery based on risk assessment

Coding Guidelines

Usage Guidelines & Examples

Follow guidelines for coding carotid artery disease and associated procedures.
Common errors include incorrect laterality and failure to document severity of stenosis.

Code Exclusions

Important Exclusions

Patients with contraindications for surgery (e.g., severe comorbidities)
Alternative codes for carotid artery stenting

Specialty Focus

Primary Specialty

Vascular Surgery

Specialty Applications

Patients with symptomatic carotid artery disease
Vascular surgery clinics and hospitals performing endarterectomy

Coding Complexity

High Complexity

This diagnosis requires careful attention to:

Comprehensive clinical documentation
Accurate code selection based on clinical criteria
Proper exclusion considerations
Specialty-specific coding guidelines

Documentation

Documentation Templates

Billing Information

Billing Considerations

Ensure proper documentation for billing
Verify code specificity requirements
Check for any additional codes needed
Review payer-specific guidelines

Common Issues

Insufficient clinical documentation
Incorrect code selection
Missing supporting diagnoses
Timing and frequency documentation

Frequently Asked Questions

What are the documentation requirements?

Documentation must include clinical indications, imaging results, and risk assessment.

What are the billing considerations?

Ensure accurate coding of diagnosis and procedure, and verify insurance coverage for carotid endarterectomy.

Carotid Endarterectomy

Diagnosis Overview

Key Clinical Considerations:

Clinical Information

Clinical Criteria & Documentation Requirements

Coding Guidelines

Usage Guidelines & Examples

Code Exclusions

Important Exclusions

Related ICD-10 Codes

Related CPT Codes

Specialty Focus

Primary Specialty

Specialty Applications

Coding Complexity

Documentation

Documentation Templates

Billing Information

Billing Considerations

Common Issues

Frequently Asked Questions

What are the documentation requirements?

What are the billing considerations?

Carotid Endarterectomy

Diagnosis Overview

Key Clinical Considerations:

Clinical Information

Clinical Criteria & Documentation Requirements

Coding Guidelines

Usage Guidelines & Examples

Code Exclusions

Important Exclusions

Related ICD-10 Codes

Related CPT Codes

Specialty Focus

Primary Specialty

Specialty Applications

Coding Complexity

Documentation

Documentation Templates

Billing Information

Billing Considerations

Common Issues

Frequently Asked Questions

What are the documentation requirements?

What are the billing considerations?