Q&A: Coding unilateral weakness post CVA

Q: I have a question regarding unilateral weakness from a previous stroke. The patient has ongoing weakness in both right arm and leg post cerebrovascular accident (CVA) and associated ataxia post CVA in 2013. Is it accurate to code I69? That doesn’t seem specific enough. And, does this map to HCC 103?

A: Great question and it reinforces the fact that it is important to pick up these late effect codes. In your example, the patient is demonstrating a late effect of unilateral weakness related to a CVA. There is an AHA Coding Clinic published First Quarter, 2015, p. 25, that states “when unilateral weakness is clearly documented as being associated with a stroke, it is considered synonymous with hemiparesis or hemiplegia.”

This reinforces the translation of the word paresis- muscular weakness caused by nerve damage or disease. Hemi- one side. Thus the documentation would support the assignment of I69.351, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side.

This will map to the assignment of HCC 103.

Editor’s Note: Laurie L. Prescott, RN, MSN, CCDS, CDIP, CRC, CDI Education Specialist at HCPro in Danvers, Massachusetts, answered this question. Contact her at lprescott@hcpro.com. For information regarding CDI Boot Camps visit www.hcprobootcamps.com/courses/10040/overview.