Hemiplegia affecting left side of ambidextrous patient G8192 Hemiplegia

Hemiplegia affecting left side of ambidextrous

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Hemiplegia affecting left side of ambidextrous patient G81.92 Hemiplegia, unspecified affecting left dominant side Explanation : Documentation states that the left side is affected and dominant is used for ambidextrous persons. Right spastic hemiplegia, unknown whether patient is right- or left-handed G81.11 Spastic hemiplegia affecting right dominant side Explanation : Since it is unknown whether the patient is right- or left-handed, if the right side is affected, the default is dominant. Elderly patient with back pain is admitted for outpatient kyphoplasty for age-related osteopathic compression fracture at vertebra T3 M80.08XA Age-related osteoporosis with current pathological fracture, vertebra(e), initial encounter for fracture Explanation : No code is assigned for the pain as it is inherent in the underlying condition being treated. Patient presents for a steroid injection for control of pain of chronic right knee due to primary degenerative joint disease G89.29 Other chronic pain M17.11 Unilateral primary osteoarthritis, right knee Explanation : Since the encounter is for control of pain, not treating the underlying condition, the pain code is sequenced first followed by the underlying condition. The M25 pain code is not necessary as the underlying condition code represents the specific site. Patient is seen to evaluate chronic left shoulder pain M25.512 Pain in left shoulder G89.29 Other chronic pain Explanation : No underlying condition has been determined yet so the pain would be the reason for the visit. The M25 pain code in this instance does not fully describe the condition as it does not represent that the pain is chronic. The G89 chronic pain code is assigned to provide specificity. Management of acute, traumatic right knee pain G89.11 Acute pain due to trauma M25.561 Pain in right knee Explanation : The reason for the encounter is to manage or control the pain, not to treat or evaluate an underlying condition. The G89 pain code is assigned as the principal diagnosis but in this instance does not fully describe the condition as it does not include the site and laterality. The M25 pain code is added to provide this information.
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Guidelines and Examples Chapter 6. Diseases of the Nervous System ICD-10-CM 2017 Chapter 6. Diseases of the Nervous System 444 ICD-10-CM 2017 2) Pain due to devices, implants and grafts See Section I.C.19. Pain due to medical devices 3) Postoperative Pain The provider’s documentation should be used to guide the coding of postoperative pain, as well as Section III. Reporting Additional Diagnoses and Section IV. Diagnostic Coding and Reporting in the Outpatient Setting . The default for post-thoracotomy and other postoperative pain not specified as acute or chronic is the code for the acute form. Routine or expected postoperative pain immediately after surgery should not be coded.
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