Spastic hemiplegia affecting right dominant side
ICD-10 G81.11 is a billable code used to indicate a diagnosis of spastic hemiplegia affecting right dominant side.
Spastic hemiplegia is a form of cerebral palsy characterized by unilateral muscle stiffness and weakness, primarily affecting the dominant side of the body. In the case of G81.11, the right side is impacted, which is significant as it often correlates with left hemisphere brain involvement. This condition arises from brain damage that occurs during fetal development, birth, or shortly after, leading to impaired motor function. Individuals with spastic hemiplegia may exhibit difficulties with fine motor skills, coordination, and balance, which can severely affect their mobility and daily activities. The condition can also lead to secondary complications such as joint deformities, muscle contractures, and associated cognitive or sensory impairments. Treatment typically involves physical therapy, occupational therapy, and sometimes surgical interventions to improve function and quality of life. Understanding the nuances of this condition is crucial for accurate coding and appropriate management of care.
Detailed neurological assessments, including motor function evaluations and cognitive assessments.
Evaluating a child with developmental delays and motor impairments.
Documenting any comorbid neurological conditions that may affect treatment.
Progress notes detailing therapy interventions, patient response, and functional outcomes.
Rehabilitation sessions focusing on improving mobility and strength in affected limbs.
Incorporating patient goals and functional limitations into documentation.
Used during physical therapy sessions to improve strength and mobility.
Document the specific exercises performed and the patient's response.
Physical therapists should note the patient's baseline and progress.
Spastic hemiplegia specifically affects one side of the body, while other types, such as spastic diplegia, affect both sides. The classification is based on the distribution of muscle tone and motor function impairment.
