Radiology Coding Alert

Reader Question:

Use ICD-10-CM Guidelines for Mono/Hemiplegia Without Dominance Designation

Question: Should I code a patient with monoplegia of the left arm as G83.22 or G83.20?

Florida Subscriber

Answer: ICD-10-CM guidelines for coding monoplegia and hemiplegia state that “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.”

This means that when the documentation specifies left or right side, you should never use code G83.20 (Monoplegia of upper limb affecting unspecified side). Additionally, you should not conclude that the left side is dominant without documentation stating so. Code G83.22 (Monoplegia of upper limb affecting left dominant side) would also be incorrect in this example. Since the left side is documented, but there is no indication of dominant versus non-dominant sides, you should refer to the guidelines above.

By default, left-sided monoplegia without specification of dominance should be coded as non-dominant under code G83.24 (Monoplegia of upper limb affecting left nondominant side).