OASIS Alert

Take note of new dominant side guidelines.

Coding for the sequelae (or late effects) of CVAs in ICD-10 is easy, thanks to a robust selection of combination codes in category I69 (Sequelae of cerebrovascular disease). Certain conditions, such as dysphagia, require you to list an additional code to further specify the diagnosis, but a helpful “Use additional code” note will tip you off when that’s the case.

New: When coding for hemiplegia, hemiparesis, and monoplegia, ICD-10 gives you the ability to report whether the condition impacts the dominant or nondominant side. When the documentation indicates the affected side, but doesn’t tell you whether it’s the patient’s dominant or nondominant side, base your choice on the following guidance:

For ambidextrous patients, the default choice is dominant.

If the left side is affected, the default choice is non-dominant.

If the right side is affected, the default choice is dominant.

Coding scenario: Your patient was admitted to home care following a CVA. He has right-sided hemiplegia and dysphagia as a result of the CVA.

You would list the following codes in the OASIS-C1 diagnosis coding slots (M1021 and M1023) for this patient:

• I69.351 (Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side);
• I69.391 (Dysphagia following cerebral infarction); and
• R13.10 (Dysphagia, unspecified).

You know the patient’s right side is the one affected by his hemiplegia, but you don’t know which side is dominant. Because his right side is affected, the default is to report this as affecting his dominant side.

When you locate I69.391 in the tabular list, you’ll find a note asking you to “Use additional code to identify the type of dysphagia, if known (R13.1-).” You don’t have any additional details about the phase of your patient’s dysphagia, so R13.10 for “unspecified” is your code.