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v1.0.0
ICD-10 Guide
ICD-10 CodesR29.702

R29.702

NIHSS score 2

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

Code Description

ICD-10 R29.702 is a billable code used to indicate a diagnosis of nihss score 2.

Key Diagnostic Point:

The NIHSS (National Institutes of Health Stroke Scale) score of 2 indicates a mild stroke or transient ischemic attack (TIA) with minimal neurological deficits. Patients scoring 2 may exhibit slight motor weakness, sensory loss, or minor speech disturbances. This score is critical in assessing the severity of a stroke and guiding treatment decisions. Common symptoms associated with a score of 2 include unilateral weakness, slight facial droop, or minor aphasia. The NIHSS is a standardized tool used to quantify the impairment caused by a stroke, and a score of 2 suggests that the patient is likely to have a favorable prognosis with appropriate intervention. Accurate assessment and documentation of the NIHSS score are essential for effective treatment planning and monitoring of patient progress.

Code Complexity Analysis

Complexity Rating: Medium

Medium Complexity

Complexity Factors

  • Variability in clinical presentation of stroke symptoms
  • Need for precise documentation of neurological deficits
  • Differentiation between stroke types (ischemic vs. hemorrhagic)
  • Potential for misclassification of severity based on subjective assessments

Audit Risk Factors

  • Inconsistent documentation of NIHSS scores
  • Failure to capture all relevant neurological deficits
  • Misinterpretation of NIHSS scoring criteria
  • Inadequate linkage between clinical findings and the assigned code

Specialty Focus

Medical Specialties

Internal Medicine

Documentation Requirements

Detailed documentation of neurological assessments, including NIHSS scores and any changes in patient condition.

Common Clinical Scenarios

Patients presenting with mild stroke symptoms in outpatient settings or during routine evaluations.

Billing Considerations

Ensure that all neurological deficits are documented to support the assigned NIHSS score.

Emergency Medicine

Documentation Requirements

Immediate and thorough documentation of NIHSS scores upon patient presentation and any subsequent changes.

Common Clinical Scenarios

Acute stroke presentations where rapid assessment and intervention are critical.

Billing Considerations

Timeliness of documentation is crucial; ensure that all assessments are recorded promptly.

Coding Guidelines

Inclusion Criteria

Use R29.702 When
  • Follow official coding guidelines for the use of R29
  • 702, ensuring that the NIHSS score is accurately documented and reflects the patient's clinical status
  • Use this code only when the score is specifically assessed and recorded

Exclusion Criteria

Do NOT use R29.702 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 2 presents to the emergency department for evaluation.

Documentation Requirements

Document the patient's NIHSS score and clinical findings to support the level of service.

Specialty Considerations

Emergency medicine providers should ensure timely and accurate documentation of neurological assessments.

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, including the NIHSS scoring system, which enhances the ability to track patient outcomes and treatment efficacy.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of stroke severity, including the NIHSS scoring system, which enhances the ability to track patient outcomes and treatment efficacy.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of stroke severity, including the NIHSS scoring system, which enhances the ability to track patient outcomes and treatment efficacy.

Resources

Clinical References

  • •
    NIHSS Training and Resources

Coding & Billing References

  • •
    NIHSS Training and Resources

Frequently Asked Questions

What does a NIHSS score of 2 indicate?

A NIHSS score of 2 indicates mild neurological impairment, often associated with minor strokes or transient ischemic attacks, and suggests a favorable prognosis with appropriate treatment.