Home Health ICD-9/ICD-10 Alert

Reader Questions:

Which Is Dominant - Brain Or Body?

Question: The patient has a late effect CVA with hemiplegia diagnosis. But the codes for cerebrovascular accident have a fifth digit for dominant or nondominant. Does this designation refer to the dominant hemisphere of the brain or the dominant side of the body?

Answer: Hemiplegia describes paralysis affecting one side of the body. Therefore, when selecting the fifth digit for 438.2x, code according to the affected side of the body (not the brain).
 
For example, code a CVA patient with left sided hemiplegia, but who is right handed, as 438.22 (Hemiplegia affecting nondominant side).

- Reader questions were reviewed by Lynda Dilts-Benson, RN, CCM, CRRN, CRNAC, LHRM, HCS-D, a consultant with Reingruber & Co. in St. Petersburg, FL.