Late effect CVA with Left or Right Hemiparesis

[jbaltimore]

Does anyone know if there is a standard side for dominant or non dominant hemiparesis with regard to Late effect CVA? (For example dominant side is Right and nondominant side is Left). Any help would be greatly appreciated!

 

[Kimmers]

Your therapist/clinician's note should include what the patient's dominant side is. Then you can use either of the following codes:

438.22 hemiplegia affecting non-dominant side as late effect of CVA
438.21 hemiplegia affecting dominant side as late effect of CVA

Hope this helps.

 

[serhaug]

left/right as it applies to dominant/nondominant side

You cannot assume left or right is dominant or nondominant. After all, if you're right-handed your right side is dominant. But there are an awful lot of us leftys out there, and stating that right side=dominant would be incorrect for us.

You would have to go with the unspecified code unless it expressly indicates dominant or nondominant.

Serine, CPC

 

[EllaC]

New guidelines instruct to use defaults when left or right is documented but dominant/non-dominant is not.
Right default = dominant
Left default = non-dominant.

ICD-10-CM Guideline c.19.d.1