Resolved Question regarding hemiplegia and Dominant/nondominant side

[CrystalP_39931]

Hello,

Please help me understand how the apply the Chp 6. guideline for hemiplegia and dominant/nondominant side. I have been coding for five years and I have only seen a provider document which side is dominant once, lol.

Let's say a patient has L hemiparesis due to MS. The provider did not document which side is dominant. Would I be correct if I coded G81.94 (Hemiplegia, unspecified affecting left nondominant side).

Does "dominant" always mean "right sided" because most of the population is right handed?

Thanks for your help,
Crystal

 

[CrystalP_39931]

Hello,

Please help me understand how the apply the Chp 6. guideline for hemiplegia and dominant/nondominant side. I have been coding for five years and I have only seen a provider document which side is dominant once, lol.

Let's say a patient has L hemiparesis due to MS. The provider did not document which side is dominant. Would I be correct if I coded G81.94 (Hemiplegia, unspecified affecting left nondominant side).

Does "dominant" always mean "right sided" because most of the population is right handed?

Thanks for your help,
Crystal

Let me clarify... does "default" mean right, because most people are right handed?

 

[CrystalP_39931]

Let me clarify... does "default" mean right, because most people are right handed?

Does default mean the affected side? In this case the left side?

 

[Lori]

It states right in the guidelines how to determine the default.

Chapter 6: Diseases of the Nervous System (G00-G99)
a. Dominant/nondominant side
Codes from category G81, Hemiplegia and hemiparesis, and subcategories
G83.1, Monoplegia of lower limb, G83.2, Monoplegia of upper limb, and G83.3,
Monoplegia, unspecified, identify whether the dominant or nondominant side is
affected. Should the affected side be documented, but not specified as dominant
or nondominant, and the classification system does not indicate a default, code
selection is as follows:
• For ambidextrous patients, the default should be dominant.
• If the left side is affected, the default is non-dominant.
• If the right side is affected, the default is dominant.

 

[CrystalP_39931]

Thank you Lori. What I'm confused about is, what do they mean by "default"? Does the default = affected side? In the example above does default = left side?

Thanks.

 

[Lori]

Yes.
The provider should document which side is affected so you know which default to use.

A code listed next to a main term in the ICD-10-CM Alphabetic Index is called a default code, The default code represents that condition that is most commonly associated with the main term, or is the unspecified code for the condition. If a condition is documented in a medical record (for example, appendicitis) without any additional information, such as acute or chronic, the default code should be assigned.

Common defaults in ICD-10:

Diabetes, if it is not stated as Type 1 or 2 the default is Type 2

Acute & Chronic the default is Acute.

A fracture not indicated as displaced or nondisplaced should be coded to displaced, and a fracture not designated as open or closed should be coded to closed.

ICD-10-CM Official Guidelines for Coding andReporting FY 2022 Page 12 of 115

18. Default codes A code listed next to a main term in the ICD-10-CM Alphabetic Index is referred to as a default code. The default code represents that condition that is most commonly associated with the main term or is the unspecified code for the condition. If a condition is documented in a medical record (for example, appendicitis) without any additional information, such as acute or chronic, the default code should be assigned.


If the affected side is documented, but not specified as dominant or non-dominant, and the classification system does not have a default, code selection is as follows:
1. If the right side is affected, the default is dominant
2. If the left side is affected, the default is non-dominant.
3. For ambidextrous patients, the default should be dominant