The code comes up 438.20 and tabular confirms Hemiplegia/hemipararesis (Late effect of CVA). You must log in or register to reply here.
In your example, the patient is demonstrating a late effect of unilateral weakness related to a CVA. There is an AHA Coding Clinic published First Quarter, 2015, p. 25, that states “when unilateral weakness is clearly documented as being associated with a stroke, it is considered synonymous with hemiparesis or hemiplegia.”
Other musculoskeletal symptoms referable to limbs Short description: Muscskel sympt limb NEC. ICD-9-CM 729.89 is a billable medical code that can be used to indicate a diagnosis on a reimbursement claim, however, 729.89 should only be used for claims with a date of service on or before September 30, 2015.
354 - Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side.
The 2022 edition of ICD-10-CM M62. 81 became effective on October 1, 2021. This is the American ICD-10-CM version of M62.
Hemiplegia, unspecified affecting left nondominant side The 2022 edition of ICD-10-CM G81. 94 became effective on October 1, 2021. This is the American ICD-10-CM version of G81.
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. The 2022 edition of ICD-10-CM R53. 1 became effective on October 1, 2021.
“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. Documenting solely to “weakness” does not influence severity or affect risk adjustment.
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.
ICD-10-CM Code for Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side I69. 354.
I69. 354 Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side.
When reporting sequela(e), you usually will need to report two codes. The first describes the condition or nature of the sequela(e) and the second describes the sequela(e) or “late effect.” For example, you may report M81.
Code Sequela of Cerebrovascular Disease/Stroke (ICD-10 code I69*) anytime post a diagnosis of any condition classifiable to ICD-10 codes I60 – I67*. 5. History of Stroke (ICD-10 code Z86. 73) should be used when the patient is being seen in an out patient setting subsequent to an inpatient stay.
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.
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.