Spastic hemiplegia affecting right nondominant side
ICD-10 G81.13 is a billable code used to indicate a diagnosis of spastic hemiplegia affecting right nondominant side.
Spastic hemiplegia is a form of cerebral palsy characterized by muscle stiffness and weakness on one side of the body. In the case of G81.13, the condition specifically affects the right nondominant side, which is typically the left side of the brain that controls motor function on the right side of the body. This condition arises from damage to the motor cortex or pathways during fetal development, birth, or early childhood. Patients may exhibit varying degrees of mobility impairment, including difficulty with fine motor skills, gait abnormalities, and challenges in performing daily activities. The spasticity can lead to muscle contractures and joint deformities over time, necessitating ongoing therapy and rehabilitation. Management often includes physical therapy, occupational therapy, and sometimes surgical interventions to improve function and quality of life. Understanding the nuances of spastic hemiplegia is crucial for accurate coding and appropriate treatment planning.
Detailed neurological examination findings, including motor function assessments and any imaging results.
Diagnosis of cerebral palsy in infants, management of spasticity, and evaluation of mobility impairments.
Ensure clear documentation of the patient's developmental milestones and any associated conditions.
Therapy progress notes, treatment plans, and functional assessments.
Rehabilitation following diagnosis, ongoing therapy for mobility improvement, and assessment of adaptive equipment needs.
Document specific goals and outcomes related to mobility and daily living activities.
Used in conjunction with G81.13 for physical therapy sessions aimed at improving strength and mobility.
Document specific exercises performed and progress made.
Physical therapists should note the patient's baseline and goals for therapy.
Spastic hemiplegia affects one side of the body, while spastic diplegia affects both sides, typically with more severe involvement of the legs.
