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ICD-10 Guide
ICD-10 CodesG81.04

G81.04

Billable

Flaccid hemiplegia affecting left nondominant side

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

Code Description

ICD-10 G81.04 is a billable code used to indicate a diagnosis of flaccid hemiplegia affecting left nondominant side.

Key Diagnostic Point:

Flaccid hemiplegia affecting the left nondominant side is a neurological condition characterized by the complete loss of voluntary muscle function on the left side of the body, which is controlled by the right hemisphere of the brain. This condition often results from damage to the motor pathways in the brain, commonly due to stroke, traumatic brain injury, or cerebral palsy. Patients may exhibit significant mobility impairments, including difficulty with balance, coordination, and performing daily activities. Flaccid hemiplegia is distinguished from spastic hemiplegia, where muscle tone is increased. Individuals with this condition may require extensive rehabilitation services, including physical therapy, occupational therapy, and speech therapy, to improve their functional abilities and quality of life. The left nondominant side refers to the side of the body that is not typically responsible for language and fine motor skills, which can influence the rehabilitation approach and expected outcomes.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Differentiating between flaccid and spastic hemiplegia
  • Identifying the underlying cause of hemiplegia
  • Documenting the extent of mobility impairments
  • Understanding the patient's functional status and rehabilitation needs

Audit Risk Factors

  • Inadequate documentation of the cause of hemiplegia
  • Failure to specify the side affected
  • Lack of detailed functional assessments
  • Misclassification of hemiplegia type

Specialty Focus

Medical Specialties

Neurology

Documentation Requirements

Comprehensive neurological examination findings, imaging results, and functional assessments.

Common Clinical Scenarios

Patients presenting with sudden onset weakness, post-stroke rehabilitation, and chronic hemiplegia management.

Billing Considerations

Ensure clear documentation of the neurological deficits and their impact on daily living.

Physical Therapy

Documentation Requirements

Detailed therapy notes outlining treatment goals, progress, and functional outcomes.

Common Clinical Scenarios

Rehabilitation sessions focusing on mobility training and strength building for hemiplegic patients.

Billing Considerations

Document specific interventions and patient responses to therapy.

Coding Guidelines

Inclusion Criteria

Use G81.04 When
  • According to ICD
  • 10 guidelines, G81
  • 04 should be used when the clinical documentation specifies flaccid hemiplegia affecting the left nondominant side
  • It is important to ensure that the documentation supports the diagnosis and includes details about the patient's functional status

Exclusion Criteria

Do NOT use G81.04 When
No specific exclusions found.

Related ICD-10 Codes

Related CPT Codes

97110CPT Code

Therapeutic exercises

Clinical Scenario

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

Documentation Requirements

Document specific exercises performed and patient progress.

Specialty Considerations

Physical therapy notes should align with the diagnosis and treatment plan.

ICD-10 Impact

Diagnostic & Documentation Impact

Enhanced Specificity

ICD-10 Improvements

The transition to ICD-10 has allowed for more specific coding of conditions like flaccid hemiplegia, improving the accuracy of patient records and facilitating better care management.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of conditions like flaccid hemiplegia, improving the accuracy of patient records and facilitating better care management.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of conditions like flaccid hemiplegia, improving the accuracy of patient records and facilitating better care management.

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 flaccid and spastic hemiplegia?

Flaccid hemiplegia is characterized by reduced muscle tone and weakness, while spastic hemiplegia involves increased muscle tone and stiffness. Accurate coding requires understanding these differences.