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v1.0.0
ICD-10 Guide
ICD-10 CodesR29.71

R29.71

NIHSS score 10-19

BILLABLE STATUSYes
IMPLEMENTATION DATEOctober 1, 2015
LAST UPDATED09/11/2025

Code Description

ICD-10 R29.71 is a billable code used to indicate a diagnosis of nihss score 10-19.

Key Diagnostic Point:

The NIHSS (National Institutes of Health Stroke Scale) score ranging from 10 to 19 indicates a moderate to severe stroke, reflecting significant neurological impairment. Patients scoring within this range typically exhibit a variety of symptoms including altered consciousness, motor deficits, sensory loss, and language difficulties. Common signs may include facial droop, arm weakness, and speech disturbances. Clinical findings often reveal unilateral weakness, with potential involvement of higher cognitive functions. Laboratory findings may show elevated blood glucose levels, electrolyte imbalances, or other metabolic derangements that could contribute to the patient's neurological status. This score is crucial for assessing the severity of a stroke and guiding treatment decisions, including the need for thrombolysis or other interventions. Accurate assessment and documentation of the NIHSS score are essential for appropriate coding and reimbursement.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in symptom presentation among patients
  • Need for precise scoring based on clinical assessment
  • Potential overlap with other neurological conditions
  • Documentation requirements for acute care settings

Audit Risk Factors

  • Inaccurate NIHSS scoring leading to incorrect coding
  • Insufficient documentation of neurological assessments
  • Failure to differentiate between stroke types
  • Inconsistent reporting of symptoms across providers

Specialty Focus

Medical Specialties

Internal Medicine

Documentation Requirements

Detailed documentation of neurological assessments, NIHSS scoring, and any comorbid conditions.

Common Clinical Scenarios

Patients presenting with stroke symptoms in a hospital setting, requiring comprehensive evaluation.

Billing Considerations

Ensure that all neurological deficits are documented and that the NIHSS score is clearly indicated.

Emergency Medicine

Documentation Requirements

Immediate documentation of NIHSS score, vital signs, and initial treatment provided.

Common Clinical Scenarios

Acute stroke presentations requiring rapid assessment and intervention.

Billing Considerations

Timeliness of documentation is critical; ensure that all findings are recorded promptly.

Coding Guidelines

Inclusion Criteria

Use R29.71 When
  • Follow the official ICD
  • CM coding guidelines, ensuring that the NIHSS score is documented accurately and correlates with the clinical findings
  • Use additional codes for any underlying conditions or complications

Exclusion Criteria

Do NOT use R29.71 When
No specific exclusions found.

Related CPT Codes

99285CPT Code

Emergency department visit, high severity

Clinical Scenario

Used when a patient presents with acute stroke symptoms and requires immediate evaluation.

Documentation Requirements

Document the NIHSS score, vital signs, and any interventions performed.

Specialty Considerations

Emergency medicine providers should ensure timely and accurate documentation to support the level of service billed.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of stroke severity, improving the accuracy of data collection and reimbursement processes. R29.71 provides a clear indication of the patient's condition, facilitating better clinical management.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of stroke severity, improving the accuracy of data collection and reimbursement processes. R29.71 provides a clear indication of the patient's condition, facilitating better clinical management.

Reimbursement & Billing Impact

reimbursement processes. R29.71 provides a clear indication of the patient's condition, facilitating better clinical management.

Resources

Clinical References

  • •
    NIHSS Training and Certification

Coding & Billing References

  • •
    NIHSS Training and Certification

Frequently Asked Questions

What does an NIHSS score of 10-19 indicate?

An NIHSS score of 10-19 indicates moderate to severe neurological impairment due to a stroke, requiring urgent medical evaluation and potential intervention.