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ICD-10 Guide
ICD-10 CodesG81.94

G81.94

Billable

Hemiplegia, unspecified affecting left nondominant side

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/05/2025

Code Description

ICD-10 G81.94 is a billable code used to indicate a diagnosis of hemiplegia, unspecified affecting left nondominant side.

Key Diagnostic Point:

Hemiplegia refers to paralysis affecting one side of the body, and in this case, it specifically affects the left side, which is considered the nondominant side for most individuals. This condition can arise from various neurological disorders, including stroke, traumatic brain injury, or cerebral palsy. Patients with left hemiplegia may experience significant mobility impairments, affecting their ability to perform daily activities. The severity of hemiplegia can vary widely, from mild weakness to complete paralysis. In children, hemiplegia may be associated with cerebral palsy, a group of disorders that affect movement and muscle tone. The management of hemiplegia often involves a multidisciplinary approach, including physical therapy, occupational therapy, and sometimes surgical interventions to improve function and mobility. Accurate coding is essential for appropriate treatment planning and reimbursement, as well as for tracking outcomes in clinical practice.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in clinical presentation and severity of hemiplegia
  • Differentiation from other types of paralysis (e.g., quadriplegia, paraplegia)
  • Need for precise documentation of affected side and dominance
  • Potential overlap with other neurological conditions

Audit Risk Factors

  • Inadequate documentation of the affected side
  • Failure to specify the type of hemiplegia
  • Misclassification of hemiplegia severity
  • Lack of supporting clinical evidence for the diagnosis

Specialty Focus

Medical Specialties

Neurology

Documentation Requirements

Detailed neurological examination findings, including motor function assessment and any imaging results.

Common Clinical Scenarios

Patients presenting with stroke, traumatic brain injury, or progressive neurological disorders.

Billing Considerations

Ensure clear documentation of the onset of symptoms and any prior history of neurological conditions.

Physical Medicine and Rehabilitation

Documentation Requirements

Functional assessments, therapy progress notes, and multidisciplinary treatment plans.

Common Clinical Scenarios

Rehabilitation following stroke or brain injury, focusing on mobility and daily living activities.

Billing Considerations

Document specific goals for rehabilitation and any assistive devices used.

Coding Guidelines

Inclusion Criteria

Use G81.94 When
  • Follow the ICD
  • CM coding guidelines for neurological conditions
  • Ensure that the documentation supports the diagnosis of hemiplegia and specifies the affected side

Exclusion Criteria

Do NOT use G81.94 When
  • Exclude conditions that may lead to similar symptoms but are not classified as hemiplegia

Related ICD-10 Codes

Related CPT Codes

97110CPT Code

Therapeutic exercises

Clinical Scenario

Used in rehabilitation for patients with hemiplegia to improve strength and mobility.

Documentation Requirements

Progress notes detailing the patient's response to therapy and specific exercises performed.

Specialty Considerations

Physical therapy documentation should include functional goals and progress towards them.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of hemiplegia, improving the accuracy of patient records and facilitating better treatment planning. G81.94 provides a clear indication of the affected side, which is crucial for rehabilitation strategies.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of hemiplegia, improving the accuracy of patient records and facilitating better treatment planning. G81.94 provides a clear indication of the affected side, which is crucial for rehabilitation strategies.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of hemiplegia, improving the accuracy of patient records and facilitating better treatment planning. G81.94 provides a clear indication of the affected side, which is crucial for rehabilitation strategies.

Resources

Clinical References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Coding & Billing References

  • •
    ICD-10-CM Official Guidelines for Coding and Reporting

Frequently Asked Questions

What is the difference between hemiplegia and hemiparesis?

Hemiplegia refers to complete paralysis of one side of the body, while hemiparesis indicates weakness on one side without complete loss of function.