AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2012 Issue 4; Ask the Editor - ICD-10-CM/PCS
Assigning Category I69 Codes (Dominant Versus Non-Dominant Side)
We appreciate the guidance provided for 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, for when the affected side is documented, but not specified as dominant or nondominant. We wonder if you can provide the same advice (or default) for codes in category I69, Sequelae of cerebrovascular disease, that relate to hemiplegia, hemiparesis and monoplegia where the codes distinguish between left and right, and dominant and nondominant. The documentation will usually specify whether the right or left side was affected, but not whether it is dominant or nondominant. We are specifically referring to codes in category I69 with fifth digits of 0, 1, 2, 3, 8 and 9, and sixth digits of 3-6 (e.g., I69.03-, I69.13-, I69.04, I69.14-, etc.). ...
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Article Overview
This article addresses a coding question about category I69 and how laterality and dominance are handled when documenting sequelae of cerebrovascular disease. It is aimed at coding professionals who work with neurologic aftercare and post-stroke sequelae documentation and need to understand the scope of the guidance being discussed.
Why This Topic Matters
Accurate reporting for post-cerebrovascular sequelae depends on matching documentation to the correct laterality and dominance concepts used by the code set. This article helps readers identify whether it is relevant to their coding questions before consulting the full guidance.
What You Will Learn
- How the article frames coding questions about laterality and dominance in category I69.
- How the discussion relates to sequelae of cerebrovascular disease and related neurologic deficits.
- What general type of guidance is being sought for documentation that does not specify dominance.
- How the article compares the I69 discussion with similar guidance for other neurologic code groups.
Who Should Read This
- Medical coders
- Coding auditors
- Clinical documentation improvement specialists
- Health information management professionals
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