Wiki Hemiplegia

[avon4117]

The physician diagnosed a patient with right-sided hemiplegia...I am lead to I69.95-...however its so confusing to determine whether its right dominant or non-dominant...any suggestions. Thanks

 

[CodingKing]

The providers should be educated with this dx they need to specify if patient is right handed, left handed or ambidextrous . But if they are not specific here it is straight from the guidelines section. The guidelines take into account the fact that a majority of people are right handed so if unknown the default is right side dominant

https://www.cms.gov/Medicare/Coding/ICD10/Downloads/2016-ICD-10-CM-Guidelines.pdf

1.C.6.a

Dominant/nondominant side

Codes from category G81, Hemiplegia and hemiparesis, and subcategories G83.1, Monoplegia of lower limb, G83.2, Monoplegia of upper limb, and G83.3, Monoplegia, unspecified, 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 non-dominant.

If the right side is affected, the default is dominant.

 

[avon4117]

thanks for the guidelines..very very helpful. What lead me to the I69- codes was the fact that the patient also have TIA..maybe I should use I69.351-?