Neurology & Pain Management Coding Alert

Question: For a patient with late effect CVA (cerebrovascular accident), or stroke, should I assign the fifth digit of hemiplegia (438.2x) to the dominant/nondominant side of the brain or the dominant/nondominant side of the body?


Rhode Island Subscriber

Answer: The basic definition of hemiplegia/hemiparesis (438.2x) is paralysis affecting one side of the body. You should therefore assess which side of the body is dominant or nondominant and code accordingly: 438.20 (Late effects of cerebrovascular disease; hemiplegia affecting unspecified side), 438.21 (... hemiplegia affecting dominant side) or 438.22 (... hemiplegia affecting nondominant side). 

For example, if a patient is right-handed and the stroke paralyzes her right side, you would select 438.21.

Remember: CVA patients are the exception to the general rule regarding coding late effects. Normally you would use two codes--one for the residual effect and a second for the cause of the condition. CVA codes, however, include both the residual effect and cause. Therefore, you should assign just one code when the late effects code includes a fourth or fifth digit describing the residual condition.