A patient has residual right sided weakness but the doctor also states new onset of right sided weakness. Hemiplegic migraine was mentioned, but then the doctor decided it was a complicated migraine. How would the new onset of right-sided weakness be coded if the patient also has the residual right-sided weakness from a previous stroke? Thank you.
Hemiplegic migraine is a complex neurological disorder. It generally includes headaches but not always. Some of the "stroke-like" symptoms can include temporary disturbances in the following:
Since the physician mentioned new onset of right-sided weakness, I would use code R53.1 Weakness accordingly. Remember, the ICD-10-CM Official Guidelines for Coding and Reporting FY 2016 Guideline .I.C.6.a , does provide direction on assignment of Sequelae of CVA codes I69.35*, I69.33* and I69.34* (6th digit required) for the side of the body affected by hemiplegia/hemiparesis and monoplegia of the upper and lower limbs.
- muscle control and body sensations, e.g., numbness, weakness or paralysis on one side of the body, which can include the arm, leg and or side of face.
- speech and language
When the affected side is specified but documentation does not indicate if it is the dominant or non-dominant side, and a default code is not included in the classification, the following guidelines should be following:
When the left side is affected, the default is non-dominant.
When the right side is affected, the default is dominant
This guideline also states that, for patients that are ambidextrous, the default should be dominant.
Leola Burke, MHSA, CCS, AHIMA-Approved ICD-10-CM/PCS Trainer, is an Independent ICD-10 Consultant.
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