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G81.92
ICD-10-CM
Left-Sided Weakness

Understanding left-sided weakness? This resource provides information on hemiparesis, left-sided body weakness, left hemiplegia, cerebrovascular accident (CVA), stroke symptoms, muscle weakness causes, neurological exam findings, ICD-10 codes for left-sided weakness, clinical documentation improvement for hemiparesis, and healthcare guidance for managing left-sided weakness. Learn about diagnosis, treatment, and support for patients experiencing left-sided weakness.

Also known as

Left Hemiparesis
Left Hemiplegia

Diagnosis Snapshot

Key Facts
  • Definition : Reduced muscle strength on the left side of the body.
  • Clinical Signs : Left arm or leg weakness, facial droop, speech difficulty, impaired balance.
  • Common Settings : Stroke, brain injury, multiple sclerosis, nerve damage.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC G81.92 Coding
G81-G83

Hemiplegia and hemiparesis

Weakness or paralysis on one side of the body.

M62.81

Other muscle weakness

Generalized or localized muscle weakness, not otherwise specified.

I60-I69

Cerebrovascular diseases

Conditions affecting blood vessels in the brain, often causing weakness.

G00-G99

Diseases of the nervous system

Broad category encompassing various neurological conditions, including weakness.

Code-Specific Guidance

Decision Tree for

Follow this step-by-step guide to choose the correct ICD-10 code.

Is weakness sudden onset?

  • Yes

    Confirmed CVA/Stroke?

  • No

    Known neurological condition?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Left-sided weakness
Hemiparesis
Left hemiplegia

Documentation Best Practices

Documentation Checklist
  • Left-sided weakness ICD-10 code documented
  • Onset and duration of weakness specified
  • Specific muscle groups affected charted
  • Impact on ADLs detailed, functional status assessed
  • Neuro exam findings: reflexes, sensation, strength

Coding and Audit Risks

Common Risks
  • Laterality Specificity

    Coding left-sided weakness requires specific documentation of affected body areas (e.g., arm, leg, face) for accurate code assignment and avoiding unspecified codes.

  • Underlying Cause

    Insufficient documentation linking left-sided weakness to a specific diagnosis (e.g., stroke, TIA, MS) may lead to inaccurate coding and impact reimbursement.

  • Hemiparesis vs. Hemiplegia

    Improper distinction between weakness (paresis) and paralysis (plegia) can result in incorrect code selection, impacting quality reporting and severity measures.

Mitigation Tips

Best Practices
  • Document laterality, onset, and progression for accurate ICD-10 coding.
  • Ensure neurological exam details support left-sided weakness diagnosis for CDI.
  • Query physician for clarity if documentation lacks specificity for HCC coding.
  • Review medical necessity criteria for related procedures/imaging per compliance guidelines.
  • Code underlying cause of weakness (e.g., stroke, TIA) for optimal reimbursement.

Clinical Decision Support

Checklist
  • Verify sudden onset: Time, symptoms (ICD-10 I69.3)
  • Assess NIHSS: Document deficits (SNOMED CT 42252007)
  • Check medical history: Stroke, TIA, trauma (ICD-10 I63.9)
  • Review medications: Anticoagulants, antiplatelets
  • Order imaging: Head CT/MRI rule out hemorrhage

Reimbursement and Quality Metrics

Impact Summary
  • Left-Sided Weakness reimbursement impacts ICD-10 coding accuracy, impacting DRG assignment and payment.
  • Coding Left-Sided Weakness specificity (e.g., stroke, hemiparesis) affects hospital case mix index CMI.
  • Accurate Left-Sided Weakness diagnosis coding impacts quality metrics reporting for stroke care and rehabilitation.
  • Left-Sided Weakness documentation quality influences physician query rates and medical necessity reviews for optimal reimbursement.

Streamline Your Medical Coding

Let S10.AI help you select the most accurate ICD-10 codes for . Our AI-powered assistant ensures compliance and reduces coding errors.

Quick Tips

Practical Coding Tips
  • Code laterality: left weakness
  • Specify onset: acute/chronic
  • Document functional impact
  • Consider hemiparesis/hemiplegia
  • R/O stroke, TIA, lesion

Documentation Templates

Patient presents with left-sided weakness, also documented as left hemiparesis.  Onset of symptoms was reported as [Date of onset] and characterized by [gradual/sudden] reduction in strength affecting the left arm and leg.  The patient reports difficulty with [specific activities of daily living affected by weakness; e.g., gripping, lifting, walking, buttoning clothing].  Neurological examination reveals [describe specific findings, e.g., decreased muscle strength graded as [Medical Research Council Scale grade] in the left upper and lower extremities, hyperreflexia, positive Babinski sign on the left].  Differential diagnosis includes stroke, transient ischemic attack (TIA), cerebral palsy, multiple sclerosis, brain tumor, and peripheral neuropathy.  Initial assessment suggests [leading suspected diagnosis, e.g., possible ischemic stroke]. Ordered [diagnostic tests, e.g., brain MRI with and without contrast, carotid ultrasound, complete blood count (CBC), basic metabolic panel (BMP)].  Plan is to admit the patient for [state reason for admission, e.g., further neurological evaluation and monitoring, stroke workup]. Treatment plan will be determined based on diagnostic findings.  ICD-10 code considerations include [relevant ICD-10 codes, e.g.,  R29.898 Other specified abnormalities of gait and mobility, M62.81 Muscle weakness (generalized), G81.1 Hemiplegia and hemiparesis affecting predominantly right dominant side affecting left non-dominant side]. CPT codes for evaluation and management services will be determined based on complexity of medical decision making.  Patient education provided regarding potential causes of left-sided weakness, diagnostic testing procedures, and plan of care.  The patient verbalized understanding.  Follow-up scheduled with neurology.