Neurology & Pain Management Coding Alert

Question: If a patient is suffering from hemiplegia, what ICD-10-CM code should I report?

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Answer: You’ll need to recheck the encounter notes or query the physician, if necessary, before choosing your diagnosis. When you look for more information, you need to attempt to identify hemiplegia type and laterality — with a twist.

First, there are two specific categories of hemiplegia diagnosis codes: G81.0- (Flaccid hemiplegia) and G81.1- (Spastic hemiplegia). If you can’t get confirmation as to what type of hemiplegia the patient has, opt for G81.9- (Hemiplegia, unspecified).

Second, the 5^th character for hemiplegia diagnoses communicates the laterality of the hemiplegia and whether the hemiplegia is affecting the patient’s dominant or nondominant side. It doesn’t matter if you’re choosing from the G81.0-, G81.1-, or G81.9- codes; you’ll complete your diagnosis with one of the following 5^th characters:

• 0 = affecting unspecified side
• 1 = affecting right dominant side
• 2 = affecting left dominant side
• 3 = affecting right nondominant side
• 4 = affecting left nondominant side.

Chris Boucher, MS, CPC, Senior Development Editor, AAPC