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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