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ICD-10 Guide
ICD-10 CodesR29.73

R29.73

NIHSS score 30-39

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

Code Description

ICD-10 R29.73 is a billable code used to indicate a diagnosis of nihss score 30-39.

Key Diagnostic Point:

The NIHSS (National Institutes of Health Stroke Scale) score of 30-39 indicates a severe stroke with significant neurological impairment. Patients scoring in this range typically exhibit profound deficits in consciousness, motor function, language, and sensory perception. Common symptoms include inability to follow commands, severe aphasia, hemiplegia, and potentially coma. This score reflects a critical condition requiring immediate medical intervention and often indicates a high risk of long-term disability or mortality. The NIHSS is a standardized tool used to assess the severity of stroke and guide treatment decisions. Accurate scoring is essential for determining the appropriate level of care and rehabilitation needs. Clinicians must document the specific deficits observed during the assessment to support the coding of R29.73, ensuring that all relevant neurological findings are captured in the patient's medical record.

Code Complexity Analysis

Complexity Rating: High

High Complexity

Complexity Factors

  • Variability in clinical presentation among patients with similar scores
  • Need for precise documentation of neurological deficits
  • Potential for overlapping symptoms with other neurological conditions
  • Requirement for comprehensive understanding of the NIHSS scoring system

Audit Risk Factors

  • Inadequate documentation of NIHSS assessment results
  • Failure to specify the neurological deficits observed
  • Misinterpretation of the NIHSS score leading to incorrect coding
  • Lack of correlation between clinical findings and documented score

Specialty Focus

Medical Specialties

Internal Medicine

Documentation Requirements

Detailed documentation of neurological assessments, including specific deficits and NIHSS score.

Common Clinical Scenarios

Patients presenting with acute stroke symptoms, requiring hospitalization for management.

Billing Considerations

Ensure that all neurological assessments are documented clearly to support the coding of R29.73.

Emergency Medicine

Documentation Requirements

Immediate and thorough documentation of NIHSS score and neurological findings upon patient arrival.

Common Clinical Scenarios

Acute stroke presentations requiring rapid assessment and intervention.

Billing Considerations

Timeliness of documentation is critical; ensure that the NIHSS score is recorded promptly to guide treatment.

Coding Guidelines

Inclusion Criteria

Use R29.73 When
  • Follow official coding guidelines for the use of R29
  • 73, ensuring that the NIHSS score is documented accurately and correlates with the clinical findings
  • Coders should reference the latest coding manuals and resources for updates on stroke coding

Exclusion Criteria

Do NOT use R29.73 When
No specific exclusions found.

Related CPT Codes

99285CPT Code

Emergency department visit, high severity

Clinical Scenario

Used when a patient with a high NIHSS score presents to the emergency department.

Documentation Requirements

Document the NIHSS score and specific neurological findings.

Specialty Considerations

Emergency medicine providers must ensure timely and accurate documentation.

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. R29.73 provides a clear indication of severe stroke, facilitating better patient management and outcomes.

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. R29.73 provides a clear indication of severe stroke, facilitating better patient management and outcomes.

Reimbursement & Billing Impact

reimbursement processes. R29.73 provides a clear indication of severe stroke, facilitating better patient management and outcomes.

Resources

Clinical References

  • •
    NIHSS Training and Certification

Coding & Billing References

  • •
    NIHSS Training and Certification

Frequently Asked Questions

What does an NIHSS score of 30-39 indicate?

An NIHSS score of 30-39 indicates severe neurological impairment due to stroke, often associated with significant deficits in consciousness, motor function, and language.