By Judy Monestime bio
ICD-10 CM’s Chapter 6 Diseases of the Nervous System (G00-G99) includes diseases of the central and peripheral nervous systems as well as epilepsy, migraine, and other headache syndromes. Many codes include a combination of conditions, such as persistent migraine aura with cerebral infarction, intractable (G43.61-).
The following conditions have been moved from ICD-9-CM Chapter 7: Diseases of the Circulatory System, to ICD-10-CM Chapter 6: basilar and carotid artery syndromes, transient global amnesia, and transient cerebral ischemic attack.
Throughout the chapter there are instructional notes to “use additional code to identify organism,” “code first underlying diseases,” “use additional code for adverse effect, if applicable, to identify drug,” and “code associated condition.” Multiple coding is frequently required to fully describe diseases of the nervous system.
Let’s discuss a new guideline in ICD-10, Coding Guideline I.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 nondominant
• If the right side is affected the default is dominant
A fifth-digit sub classification is included in category G81-G83 to identify whether the dominant or nondominant side of the body is affected. This type of specificity may not be provided in the health record; if the information is not available, assign the fifth digit 0. However, if the affected side is documented but not specified as the dominant or nondominant side for the patient, and the classification does not provide a default code, the code is based on the guideline above.
Let’s practice! How do you code the following encounter?
Situation: Patient is seen today for hemiparesis of the left side.
Coding: G81.94 Hemiplegia, unspecified affecting left nondominant side
Rationale: Review Coding Guideline I.C.6.a. Dominant/Nondominant Side
Judy Monestime, MBA, CDIP, CPC, is an AHIMA-approved ICD-10-CM/PCS trainer.
