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v1.0.0
ICD-10 Guide
ICD-10 CodesR29.716

R29.716

NIHSS score 16

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

Code Description

ICD-10 R29.716 is a billable code used to indicate a diagnosis of nihss score 16.

Key Diagnostic Point:

The NIHSS (National Institutes of Health Stroke Scale) score of 16 indicates a moderate to severe stroke, reflecting significant neurological impairment. This score is derived from a comprehensive assessment of various neurological functions, including consciousness, language, motor skills, sensory perception, and visual fields. A score of 16 suggests that the patient exhibits considerable deficits, which may include aphasia, hemiparesis, and impaired coordination. The NIHSS is a critical tool in both the diagnosis and management of stroke, guiding treatment decisions and prognostic evaluations. Clinicians utilize this score to determine the severity of the stroke and to monitor changes in the patient's condition over time. Accurate documentation of the NIHSS score is essential for coding and billing purposes, as it directly influences the treatment protocols and potential reimbursement levels.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in documentation of NIHSS assessments
  • Need for precise scoring interpretation
  • Potential overlap with other neurological codes
  • Requirement for comprehensive clinical context

Audit Risk Factors

  • Inconsistent documentation of NIHSS scores
  • Failure to include clinical context for scoring
  • Misinterpretation of score implications
  • Inadequate follow-up documentation

Specialty Focus

Medical Specialties

Internal Medicine

Documentation Requirements

Detailed documentation of neurological assessments, including NIHSS scores, patient history, and treatment plans.

Common Clinical Scenarios

Patients presenting with acute stroke symptoms, requiring immediate assessment and intervention.

Billing Considerations

Ensure that all components of the NIHSS are documented to support the assigned score.

Emergency Medicine

Documentation Requirements

Acute care documentation must include time of onset, NIHSS score, and immediate interventions performed.

Common Clinical Scenarios

Patients arriving at the emergency department with sudden onset of neurological deficits.

Billing Considerations

Timeliness of documentation is critical; ensure that the NIHSS score is recorded promptly after assessment.

Coding Guidelines

Inclusion Criteria

Use R29.716 When
  • Follow the official ICD
  • CM coding guidelines, ensuring that the NIHSS score is documented accurately and correlates with the clinical findings
  • The score should be supported by a comprehensive assessment of the patient's neurological status

Exclusion Criteria

Do NOT use R29.716 When
No specific exclusions found.

Related CPT Codes

99285CPT Code

Emergency department visit, high severity

Clinical Scenario

Used when a patient with a NIHSS score of 16 presents to the emergency department.

Documentation Requirements

Document the patient's condition, NIHSS score, and treatment plan.

Specialty Considerations

Emergency medicine specialists should ensure timely and accurate documentation.

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 clinical data and reimbursement processes. R29.716 provides a clear indication of the patient's neurological status, which is critical for treatment planning.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of stroke severity, improving the accuracy of clinical data and reimbursement processes. R29.716 provides a clear indication of the patient's neurological status, which is critical for treatment planning.

Reimbursement & Billing Impact

reimbursement processes. R29.716 provides a clear indication of the patient's neurological status, which is critical for treatment planning.

Resources

Clinical References

  • •
    NIHSS Training and Resources

Coding & Billing References

  • •
    NIHSS Training and Resources

Frequently Asked Questions

What does an NIHSS score of 16 indicate?

An NIHSS score of 16 indicates moderate to severe neurological impairment, suggesting significant deficits that require urgent medical attention.