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v1.0.0
ICD-10 Guide
ICD-10 CodesR29.738

R29.738

NIHSS score 38

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

Code Description

ICD-10 R29.738 is a billable code used to indicate a diagnosis of nihss score 38.

Key Diagnostic Point:

The NIHSS (National Institutes of Health Stroke Scale) score of 38 indicates a severe stroke, reflecting significant neurological impairment. This score is derived from a comprehensive assessment of various neurological functions, including consciousness, language, motor skills, sensory perception, and visual fields. A score of 38 suggests profound deficits, with the patient likely exhibiting symptoms such as complete loss of motor function on one side, severe aphasia, and possibly altered consciousness. The NIHSS is crucial for determining the severity of a stroke and guiding treatment decisions, including the need for thrombolysis or other interventions. Accurate scoring is essential for effective communication among healthcare providers and for research purposes. In clinical practice, a score of 38 necessitates immediate and intensive medical intervention, often in an acute care setting, to optimize patient outcomes and minimize long-term disability.

Code Complexity Analysis

Complexity Rating: High

High Complexity

Complexity Factors

  • Requires precise assessment of multiple neurological functions.
  • High variability in patient presentation and scoring interpretation.
  • Need for interdisciplinary collaboration for accurate scoring.
  • Potential for rapid changes in patient condition affecting score.

Audit Risk Factors

  • Inaccurate scoring leading to inappropriate coding.
  • Failure to document all neurological deficits assessed.
  • Lack of interdisciplinary documentation supporting the score.
  • Misinterpretation of NIHSS components.

Specialty Focus

Medical Specialties

Internal Medicine

Documentation Requirements

Detailed documentation of neurological assessments, including NIHSS components and patient history.

Common Clinical Scenarios

Patients presenting with acute stroke symptoms requiring hospitalization and intensive monitoring.

Billing Considerations

Consideration of comorbidities that may affect neurological assessment.

Emergency Medicine

Documentation Requirements

Immediate documentation of NIHSS score upon patient arrival, including time of onset and treatment administered.

Common Clinical Scenarios

Acute stroke presentations requiring rapid intervention and assessment.

Billing Considerations

Documentation must reflect the urgency of care and any interventions performed.

Coding Guidelines

Inclusion Criteria

Use R29.738 When
  • Follow official ICD
  • CM guidelines for coding symptoms and signs, ensuring that the NIHSS score is documented accurately and reflects the patient's clinical status

Exclusion Criteria

Do NOT use R29.738 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 38 is evaluated in the emergency department.

Documentation Requirements

Document the severity of the condition and the NIHSS score.

Specialty Considerations

Emergency medicine providers must ensure timely 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, improving the accuracy of clinical data and treatment planning.

ICD-9 vs ICD-10

The transition to ICD-10 has allowed for more specific coding of stroke severity, improving the accuracy of clinical data and treatment planning.

Reimbursement & Billing Impact

The transition to ICD-10 has allowed for more specific coding of stroke severity, improving the accuracy of clinical data and treatment planning.

Resources

Clinical References

  • •
    NIHSS Training and Certification

Coding & Billing References

  • •
    NIHSS Training and Certification

Frequently Asked Questions

What does a NIHSS score of 38 indicate?

A NIHSS score of 38 indicates severe neurological impairment, often associated with significant stroke, requiring immediate medical intervention.