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G81.91
ICD-10-CM
Right-Sided Hemiparesis

Understanding Right-Sided Hemiparesis: Find information on diagnosis, treatment, and prognosis. Explore resources for healthcare professionals, including clinical documentation tips, ICD-10 codes for hemiparesis, and medical coding guidelines. Learn about causes, symptoms, and rehabilitation strategies for right-sided hemiparesis. This resource provides valuable insights for physicians, nurses, therapists, and medical coders dealing with right hemiparesis.

Also known as

Right Hemiplegia
Right-Sided Weakness

Diagnosis Snapshot

Key Facts
  • Definition : Weakness on the right side of the body.
  • Clinical Signs : Right-sided arm and leg weakness, facial droop, speech difficulty.
  • Common Settings : Stroke, brain injury, cerebral palsy, multiple sclerosis.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC G81.91 Coding
G81

Hemiplegia and hemiparesis

Weakness or paralysis on one side of the body.

I60-I69

Cerebrovascular diseases

Conditions affecting blood vessels in the brain, a common cause of hemiparesis.

G00-G99

Diseases of the nervous system

Encompasses various neurological disorders, including hemiparesis.

Code-Specific Guidance

Decision Tree for

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

Is hemiparesis due to cerebrovascular disease?

  • Yes

    Is it specified as infantile cerebral palsy?

  • No

    Is it due to other specified cause?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Right-sided weakness
Left Hemisphere Stroke
Right Hemiplegia

Documentation Best Practices

Documentation Checklist
  • Document laterality (right-sided weakness)
  • Specify onset (sudden, gradual)
  • Detail muscle groups affected
  • Assess functional impact (ADLs)
  • Include relevant diagnostic testing (e.g., imaging, EMG)

Coding and Audit Risks

Common Risks
  • Laterality Miscoding

    Incorrect coding of affected side (right vs. left) leading to inaccurate documentation and claims.

  • Specificity Deficiency

    Lack of detail regarding hemiparesis severity (e.g., mild, moderate, severe) impacting reimbursement.

  • Underlying Cause Omission

    Failure to code the underlying condition causing right-sided hemiparesis (e.g., stroke, trauma) for proper clinical documentation improvement.

Mitigation Tips

Best Practices
  • Accurate ICD-10 coding (e.g., I69.358) for right hemiparesis crucial for reimbursement.
  • Thorough neurological exam documentation supports right hemiparesis diagnosis for compliance.
  • Timely CDI clarifies right hemiparesis laterality, etiology, and acuity for optimal care.
  • Distinguish between right hemiparesis and hemiplegia in documentation for accurate coding.
  • Regular assessment of right hemiparesis severity aids in tracking progress and adjusting care.

Clinical Decision Support

Checklist
  • 1. Sudden weakness in right arm/leg? Document onset, severity.
  • 2. Rule out stroke mimics (e.g., seizure, migraine). ICD-10 G81.9
  • 3. Assess for facial droop, speech changes. NIHSS documented?
  • 4. Imaging (CT/MRI brain) ordered and reviewed? Document findings.

Reimbursement and Quality Metrics

Impact Summary
  • Right-Sided Hemiparesis reimbursement hinges on accurate ICD-10 coding (I69.3*) and medical record documentation.
  • Coding errors impact hemiparesis DRG assignment, affecting hospital reimbursement and case mix index.
  • Quality metrics for right hemiparesis include functional improvement, stroke severity scales, and discharge disposition.
  • Accurate coding and documentation are crucial for hemiparesis patient outcomes reporting and quality improvement initiatives.

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 G81.9 for unspecified hemiparesis
  • Document right side weakness specifics
  • Confirm laterality in documentation
  • ICD-10 hemiparesis code G81
  • Consider M62.81 for muscle weakness

Documentation Templates

Patient presents with right-sided hemiparesis, characterized by weakness affecting the right side of the body.  Onset of right hemiparesis was noted on [date of onset], with [acute, subacute, or chronic] progression.  Patient reports [symptoms, e.g., difficulty with ambulation, decreased grip strength on the right side, right-sided facial droop].  Neurological examination reveals [detailed findings, e.g., decreased muscle strength in right upper and lower extremities, graded [muscle strength grade using Medical Research Council scale], hyperreflexia on the right side, positive Babinski sign on the right].  Differential diagnosis includes cerebrovascular accident (CVA), stroke, transient ischemic attack (TIA), brain tumor, multiple sclerosis, traumatic brain injury, and spinal cord injury.  Diagnostic workup includes [list tests, e.g., MRI brain, CT scan head, carotid ultrasound, electromyography (EMG), nerve conduction study (NCS)].  Initial treatment plan includes [list treatments, e.g., physical therapy, occupational therapy, speech therapy, pharmacologic management for spasticity or pain management].  Patient education provided on right-sided hemiparesis management, stroke rehabilitation, fall prevention strategies, and medication adherence.  Follow-up scheduled for [date] to assess treatment response and adjust plan as needed.  ICD-10 code G81.9 (Hemiplegia and hemiparesis, unspecified) and relevant CPT codes for evaluation and management, diagnostic testing, and therapeutic interventions will be used for billing and coding purposes.  Prognosis for recovery from right hemiparesis is dependent on the underlying cause and patient's response to treatment.