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v1.0.0
ICD-10 Guide
ICD-10 CodesR29.736

R29.736

NIHSS score 36

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

Code Description

ICD-10 R29.736 is a billable code used to indicate a diagnosis of nihss score 36.

Key Diagnostic Point:

The NIHSS (National Institutes of Health Stroke Scale) score of 36 indicates a severe stroke, reflecting significant neurological impairment. This score is derived from a comprehensive assessment of various neurological functions, including consciousness, vision, motor function, sensation, language, and neglect. A score of 36 suggests that the patient exhibits profound deficits across multiple domains, which may include inability to follow commands, severe motor weakness, and potential loss of consciousness. Such a high score typically correlates with a high risk of morbidity and mortality, necessitating immediate and intensive medical intervention. Clinicians must document the specific deficits observed during the assessment to support the coding of this condition accurately. The NIHSS is a critical tool in both acute stroke management and research, providing a standardized method for quantifying stroke severity and guiding treatment decisions.

Code Complexity Analysis

Complexity Rating: High

High Complexity

Complexity Factors

  • Requires detailed documentation of neurological deficits
  • High variability in patient presentation and scoring
  • Potential for misinterpretation of NIHSS scores
  • Need for correlation with clinical findings and imaging results

Audit Risk Factors

  • Inadequate documentation of NIHSS assessment
  • Failure to correlate NIHSS score with clinical findings
  • Misclassification of stroke severity
  • Inconsistent scoring by different clinicians

Specialty Focus

Medical Specialties

Internal Medicine

Documentation Requirements

Thorough documentation of neurological assessments, including NIHSS scoring and any relevant imaging studies.

Common Clinical Scenarios

Patients presenting with acute stroke symptoms, requiring immediate evaluation and management.

Billing Considerations

Ensure that all neurological deficits are documented clearly to support the NIHSS score and subsequent coding.

Emergency Medicine

Documentation Requirements

Detailed acute care documentation, including time of onset, NIHSS score, and interventions initiated.

Common Clinical Scenarios

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

Billing Considerations

Rapid assessment and documentation are crucial for accurate coding and treatment planning.

Coding Guidelines

Inclusion Criteria

Use R29.736 When
  • Follow the official ICD
  • CM coding guidelines, ensuring that the NIHSS score is documented accurately and correlates with clinical findings
  • Use additional codes to capture any underlying conditions or complications

Exclusion Criteria

Do NOT use R29.736 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 36 is evaluated in the emergency department.

Documentation Requirements

Document the level of service, including time spent and complexity of medical decision-making.

Specialty Considerations

Emergency medicine specialists should ensure that all acute interventions are documented.

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. R29.736 provides a clear indication of severe neurological impairment, which is critical for treatment planning and resource allocation.

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. R29.736 provides a clear indication of severe neurological impairment, which is critical for treatment planning and resource allocation.

Reimbursement & Billing Impact

reimbursement processes. R29.736 provides a clear indication of severe neurological impairment, which is critical for treatment planning and resource allocation.

Resources

Clinical References

  • •
    NIH Stroke Scale Training

Coding & Billing References

  • •
    NIH Stroke Scale Training

Frequently Asked Questions

What does an NIHSS score of 36 indicate?

An NIHSS score of 36 indicates severe neurological impairment, often associated with a high risk of morbidity and mortality. It reflects significant deficits in multiple neurological functions.