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ICD-10 Guide
ICD-10 CodesG81.92

G81.92

Billable

Hemiplegia, unspecified affecting left dominant side

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

Code Description

ICD-10 G81.92 is a billable code used to indicate a diagnosis of hemiplegia, unspecified affecting left dominant side.

Key Diagnostic Point:

Hemiplegia refers to paralysis of one side of the body, which can result from various neurological conditions, including stroke, traumatic brain injury, or cerebral palsy. In the case of G81.92, the hemiplegia is unspecified, indicating that the exact cause or nature of the paralysis has not been clearly defined. This code specifically affects the left dominant side, which is significant as it may impact the patient's ability to perform daily activities, communicate, and engage socially. Patients with left-sided hemiplegia may experience weakness or complete loss of motor function on the left side, leading to mobility impairments and challenges in coordination. The condition can also affect speech and cognitive functions, depending on the area of the brain that is impacted. Rehabilitation strategies often include physical therapy, occupational therapy, and speech therapy to enhance mobility and independence. Understanding the nuances of this condition is crucial for accurate coding and effective treatment planning.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Unspecified nature of the hemiplegia complicates diagnosis.
  • Requires understanding of left-sided dominance in patients.
  • Potential overlap with other neurological conditions.
  • Need for comprehensive documentation to support coding.

Audit Risk Factors

  • Inadequate documentation of the patient's dominant side.
  • Failure to specify the underlying cause of hemiplegia.
  • Misclassification of hemiplegia severity.
  • Inconsistent coding across different encounters.

Specialty Focus

Medical Specialties

Neurology

Documentation Requirements

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

Common Clinical Scenarios

Patients presenting with stroke, traumatic brain injury, or progressive neurological disorders.

Billing Considerations

Consideration of comorbid conditions that may affect mobility and rehabilitation outcomes.

Physical Medicine and Rehabilitation

Documentation Requirements

Functional assessments, therapy progress notes, and multidisciplinary team evaluations.

Common Clinical Scenarios

Patients undergoing rehabilitation post-stroke or with chronic neurological conditions.

Billing Considerations

Focus on the patient's rehabilitation goals and progress towards independence.

Coding Guidelines

Inclusion Criteria

Use G81.92 When
  • According to ICD
  • 10 guidelines, G81
  • 92 should be used when hemiplegia is present without a specified cause
  • Coders must ensure that documentation supports the diagnosis and reflects the patient's dominant side

Exclusion Criteria

Do NOT use G81.92 When
  • Exclusion criteria include conditions that specify the cause of hemiplegia

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

Documentation of the patient's functional status and therapy goals.

Specialty Considerations

Physical therapy notes should reflect progress and changes in the patient's condition.

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 hemiplegia, improving the accuracy of patient records and treatment plans. G81.92 provides a means to capture cases where the cause is not specified, but it also emphasizes the need for thorough documentation.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of conditions like hemiplegia, improving the accuracy of patient records and treatment plans. G81.92 provides a means to capture cases where the cause is not specified, but it also emphasizes the need for thorough documentation.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of conditions like hemiplegia, improving the accuracy of patient records and treatment plans. G81.92 provides a means to capture cases where the cause is not specified, but it also emphasizes the need for thorough documentation.

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 hemiplegia and hemiparesis?

Hemiplegia refers to complete paralysis of one side of the body, while hemiparesis indicates weakness on one side. Both conditions can result from similar underlying causes, but the severity of motor function loss distinguishes them.