ICD 10 Coding Alert

Question: A provider documents a patient having hemiplegia after a stroke but doesn’t specify which side the hemiplegia affects. Does the side matter?

Washington Subscriber

Answer: It’s important to have as much information as possible, both for the patient’s benefit, in portraying an accurate depiction of their condition in the medical narrative, and for the comprehensiveness of the documentation.

When reporting the aftereffects of cerebrovascular disease like stroke, you do need to specify the side affected, according to the ICD-10-CM Official Guidelines for Coding and Reporting. The Guidelines say:

“Codes from category I69, Sequelae of cerebrovascular disease, that specify hemiplegia, hemiparesis, and monoplegia identify whether the dominant or nondominant side is affected. Should the affected side be documented but not specified as dominant or nondominant, and the classification system does not indicate a default, code selection is as follows:

• “For ambidextrous patients, the default should be dominant.
• “If the left side is affected, the default is nondominant.
• “If the right side is affected, the default is dominant.”

While querying is your best first step, it’s also helpful to know that there are default descriptions for the condition of hemiplegia.

You’ll look to ICD-10-CM code I69.35- (Hemiplegia and hemiparesis following cerebral infarction) and choose the most specific code, according to the respective 6^th character, once you have the information about which side is affected and which side of the patient’s body is naturally dominant. 

Rachel Dorrell, MA, MS, CPC-A, CPPM, Production Editor, AAPC