Cardiology Coding Alert

Question: We get many complete carotid duplex reports that state weakness, syncope, mild plaque formation but show no evidence of significant carotid stenosis. I think the physician is checking if stenosis is causing the syncope. Which diagnosis code should we use?

New York Subscriber

Answer: You should choose the diagnosis code based on what your complete carotid duplex scan shows.

No results: If it does not explain why the patient is having syncope, you'll have to code the syncope, the signs and symptoms, rather than the underlying condition, as the primary diagnosis. In other words, your ICD-9 manual instructs you that "if symptoms are present but a definitive diagnosis has not yet been determined, code the symptoms." You should still report the complete carotid duplex using 93880 (Duplex scan of extracranial arteries; complete bilateral study).

Remember: Because the cause is still unknown, you will probably report 780.2 (Syncope and collapse), which includes cardiac and vasoconstriction syncope. But you have to code what's documented, and if there is a more specific syncope listed, code for that. For example, you could choose 337.0, which includes carotid sinus syncope.

Results: However, if the scan reveals stenosis, then you should report that. To code for the plaque and any stenosis, determine if it's in one artery or both.

If the problem is in one artery, report 433.10 (Occlusion and stenosis of precerebral arteries; carotid artery; without mention of cerebral infarction). If the problem is in both arteries, report 433.30 (... multiple and bilateral ...). You might also want to report the underlying symptoms that necessitated the exam as secondary/ additional diagnoses to give the full picture.