Pain Management Coding Alert

Question: The physician performs a level-three evaluation and management (E/M) service for an established patient. Notes indicate that the patient has “flaccid hemiplegia.” How should I report this encounter?

Indiana Subscriber

Answer: It depends on the patient’s dominant hand; ICD-10 code choice hinges on this detail.

On the claim, you’ll report 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: an expanded problem focused history; an expanded problem focused examination; medical decision making of low complexity…) for the E/M.

Then, you’ll choose one of the following diagnoses, depending on the patient:

• G81.00, Flaccid hemiplegia affecting unspecified side
• G81.01, ... affecting right dominant side
• G81.02, … affecting left dominant side
• G81.03, … affecting right nondominant side
• G81.04, … affecting left nondominant side.

Remember spastic, flaccid hemiplegia differences: A couple of conditions that could trip up coders when it comes to selecting diagnosis codes are spastic and flaccid hemiplegia; they have different diagnosis codes, but their symptoms can be similar.

If a patient suffers from spastic hemiplegia, you’ll choose from one of the following ICD-10 codes, depending on the patient:

• G81.10, Spastic hemiplegia affecting unspecified side
• G81.11, ... affecting right dominant side
• G81.12, … affecting left dominant side
• G81.13, … affecting right nondominant side
• G81.14, … affecting left nondominant side.

The difference between the two lies in the tone of the paralyzed muscles. In spastic hemiplegia, the muscle tone increases and the muscles stiffen. In flaccid hemiplegia, there is loss of muscle tone and the body becomes limp. Spastic hemiplegia reflects a primarily upper motor neuron dysfunction that develops sometime after the original brain injury; whereas a flaccid hemiplegia typically occurs in the acute phase of the original brain injury.