Assesment: CVA with left sided weakness (unspecified dominant or nondominate sided) By definition, hemiparesis = weakness, therefore I would conclude that the correct code would be 438.20 (late effect of CVA with hemiparesis/hemiplegia). There are many debates, with out a concise direction, for this code I would appreciate some guidance, please
Assign code 438.89, Other late effects of cerebrovascular disease and code 728.87, Muscle weakness, for residual muscle weakness secondary to late effect of cerebrovascular accident." thank you! I just had this same DX. In the encoder I put late/effect/CVA/hemiplegia/ unspecified (because it doesn't say whether left side was dominant or not.
Assesment: CVA with left sided weakness (unspecified dominant or nondominate sided) The definition of hemiparesis is the partial paralysis of one side of the body, not weakness. From the medical dictionary and stroke.about.com, the following are defined:
ICD-10-CM Diagnosis Code K51.50 [convert to ICD-9-CM] Left sided colitis without complications Chronic left-sided ulcerative colitis; Ulcerative colitis, left sided, chronic; Left sided colitis NOS ICD-10-CM Diagnosis Code R53.1 [convert to ICD-9-CM]
ICD-10-CM Code for Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side I69. 354.
“Weakness” is code 728.87 ICD-9, M62. 81 ICD-10, which is NOT A HCC. “Weakness” is a symptom, whereas “paresis” including monoparesis, hemiparesis and even quadriparesis are diagnoses.
Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. I69. 354 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes.
Unspecified sequelae of cerebral infarction I69. 30 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. The 2022 edition of ICD-10-CM I69. 30 became effective on October 1, 2021.
Code category I69* (Sequelae of cerebrovascular disease) specifies the type of stroke that caused the sequelae (late effect) as well as the residual condition itself.
Coding Guidelines Residual neurological effects of a stroke or cerebrovascular accident (CVA) should be documented using CPT category I69 codes indicating sequelae of cerebrovascular disease. Codes I60-67 specify hemiplegia, hemiparesis, and monoplegia and identify whether the dominant or nondominant side is affected.
R53. 1 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes.
Injury to the left side of the brain, which controls language and speaking, can result in right-sided weakness. Left-sided weakness results from injury to the right side of the brain, which controls nonverbal communication and certain behaviors.
Hemiparesis is a mild or partial weakness or loss of strength on one side of the body. Hemiplegia is a severe or complete loss of strength or paralysis on one side of the body. The difference between the two conditions primarily lies in severity.
I63. 9 - Cerebral infarction, unspecified | ICD-10-CM.
ICD-10 code M62. 81 for Muscle weakness (generalized) is a medical classification as listed by WHO under the range - Soft tissue disorders .
ICD-10 code: I63. 9 Cerebral infarction, unspecified.
In the encoder I put late/effect/CVA/hemiplegia/ unspecified (because it doesn't say whether left side was dominant or not. The code comes up 438.20 and tabular confirms Hemiplegia/hemipararesis (Late effect of CVA).
Go with 438.89. Look at the tip under 438.89 in the ICD-9 expert. Use 728.87 as your secondary code for residual weakness due to CVA.