Documentation of Weakness following CVA - Molina Healthcare
[Pages:1]Molina Healthcare Coding Education Documentation of Weakness following CVA
I documented "left side weakness d/t CVA." Why did this not risk adjust?
"Weakness" is code 728.87 ICD-9, M62.81 ICD-10, which is NOT A HCC.
"Weakness" is a symptom, whereas "paresis" including monoparesis, hemiparesis and even quadriparesis are diagnoses.
Documenting solely to "weakness" does not influence severity or affect risk adjustment.
Document whether the "paresis" impacts the dominant or nondominant side: ICD-10 presumes the right side to be dominant unless stated otherwise.
Note: In ICD-9CM and ICD-10, hemiparesis and hemiplegia share the same code.
Note: Weakness of a side can be interpreted to be hemiparesis if attributed to a stroke. Not for a single extremity.
Documentation Examples:
A/P: 62 year old female s/p CVA with related dominant right side weakness
Assessment: New onset right hemiparesis
HCC/ICD-9 Code: 438.40 HCC/ICD-10 Code: I69.351
Plan: Refer to neuro rehab now.
A/P:
Established 72 year old male with RUE weakness after CVA
Assessment: Right arm weakness d/t CVA. Stable
Non-HCC/ICD-9 Code: 728.87 Non-HCC/ICD-10 Code: M62.81
Plan: Continue PT
A/P:
Established 72 year old male with RUE weakness after CVA
Assessment: Right arm monoparesis d/t CVA. Stable
HCC/ICD-9 Code: 438.40 HCC/ICD-10 Code: I69.331
Plan: Continue PT
Have Questions? Contact: Ramp@
The information presented herein is for informational and illustrative purposes only. It is not intended, nor is it to be used, to define a standard of care or otherwise substitute for informed medical evaluation, diagnosis and treatment which can be performed by a qualified medical professional. Molina Healthcare Inc. does not warrant or represent that the information contained herein is accurate or free from defects.
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