July 25, 2011

ICD-10-CM Official Guidelines 2011 Provides Guidance for Assignment of Codes for Hemiparesis

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ICD-9-CM provides codes for hemiparesis without further specification (342.0x-342.9x) and hemiparesis as a late effect of cerebrovascular disease (438.20-438.22).

Fifth digits specify the side of the body affected by the hemiplegia/hemiparesis, but guidance for assignment of the fifth digit, which also indicates the dominant/non-dominant side of the body, is not provided by the Official ICD-9-CM Coding Guidelines. The coder generally reviews the health record for documentation identifying the dominant side of the body or looks for documentation indicating whether the patient is left- or right-handed.

The ICD-10-CM Official Guidelines for Coding and Reporting 2011, Guideline I.C.6.a, however, does provide direction on assignment of codes for the side of the body affected by hemiplegia/hemiparesis and monoplegia of the upper and lower limbs.

When the affected side is specified but documentation does not indicate if it is the dominant or non-dominant side, and a default code is not included in the classification, the following guidelines should be followed:

    • When the left side is affected, the default is non-dominant.
    • When the right side is affected, the default is dominant.

This guideline also states that, for patients that are ambidextrous, the default should be dominant.

 


 

Examples:

For patients transferred to an inpatient rehabilitation facility (IRF) following initial treatment of a traumatic brain injury, an ICD-10-CM code from the S06 category is reported with a seventh character of “S” to indicate that the admission is for treatment of the sequela and not the initial treatment for the injury.

The following table shows the ICD-9-CM and ICD-10-CM codes that would be assigned when hemiplegia is the residual condition that requires rehabilitation.

Scenario

ICD-10-CM

ICD-9-CM

Traumatic brain injury with left-sided hemiplegia

G81.94 Hemiplegia, unspecified, affecting left non-dominant side

342.90 Hemiplegia, unspecified, affecting unspecified side

Traumatic brain injury suffered by left-handed patient with left-sided hemiplegia

G81.92 Hemiplegia, unspecified, affecting left dominant side

342.91 Hemiplegia, unspecified, affecting dominant side

Traumatic brain injury suffered by right-handed patient with right-sided hemiplegia

G81.91 Hemiplegia, unspecified, affecting right dominant side

342.91 Hemiplegia, unspecified, affecting dominant side

Traumatic brain injury suffered by left-handed patient with right-sided hemiplegia

G81.93 Hemiplegia, unspecified affecting right non-dominant side

342.92 Hemiplegia, unspecified affecting non-dominant side

Traumatic brain injury with hemiplegia

G81.90 Hemiplegia, unspecified, affecting unspecified side

342.90 Hemiplegia, unspecified affecting unspecified side

 

Physicians do not always include documentation that identifies the dominant side of the body. One solution to this problem is to assign responsibility for documenting the patient’s dominant hand by including a field for recording this information in the physical therapy, occupational therapy or nursing initial evaluations.

If coders currently are not reporting codes for the specific side of the body involved, they may require education on how to determine the dominant side and where to find indicators in the documentation.

About the Author

Patricia Trela, RHIA, is the director of HIM and rehabilitation services for Diskriter, Inc., a consulting firm offering integrated HIM rehabilitation consulting services, including HIM Interim management, IRF PPS compliance and education, coding and auditing support, dictation/transcription, and other solutions. Pat facilitates the AHIMA Coding Physical Medicine Rehabilitation Community of Practice (COP).

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