ICD-10 Code for Complete Left-Sided Motor and Sensory Loss Following Embolic CVA
The appropriate ICD-10 code for complete left-sided motor and sensory loss following embolic cerebrovascular accident (CVA) is I63.4 (Cerebral infarction due to embolism of cerebral arteries) with additional code G81.04 (Flaccid hemiplegia and hemiparesis affecting right dominant side).
Understanding the Coding Requirements
- The primary diagnosis should reflect the embolic stroke as the underlying cause, which is coded as I63.4 (Cerebral infarction due to embolism of cerebral arteries) 1
- The neurological deficit (complete motor and sensory loss) should be coded separately as a manifestation of the stroke 1
- Since the question specifies left-sided deficits, this indicates right brain involvement, resulting in contralateral (opposite side) symptoms 2
Primary Code Selection
- I63.4 is the appropriate code for embolic cerebrovascular accident (CVA) 1
- This code specifically identifies the embolic etiology, which is important for proper classification and treatment planning 1
Secondary Code for Neurological Deficit
- G81.04 (Flaccid hemiplegia and hemiparesis affecting right dominant side) should be used to document the complete motor loss 3
- R20.0 (Anesthesia of skin) can be added to document the sensory component of the deficit 3
Assessment of Deficit Severity
- The National Institutes of Health Stroke Scale (NIHSS) should be used to quantify the severity of the neurological deficit 3
- Complete motor loss would score a 4 on items 5 and 6 of the NIHSS (for arm and leg motor function) 3
- Complete sensory loss would score a 2 on item 8 (sensory) of the NIHSS 3
Additional Considerations
- If the patient has aphasia due to left hemisphere involvement, an additional code of R47.01 (Aphasia) may be appropriate 2
- If the stroke occurred during the current hospitalization, the appropriate Present on Admission (POA) indicator should be assigned 1
- For accurate coding, documentation should include the specific arterial distribution affected (e.g., middle cerebral artery) if known 1
Coding Pitfalls to Avoid
- Do not use I69 series codes (sequelae of cerebrovascular disease) for acute stroke presentations 1
- Avoid using symptom codes (R series) as the primary diagnosis when a definitive diagnosis of stroke has been established 1
- Do not confuse embolic stroke (I63.4) with thrombotic stroke (I63.3) or hemorrhagic stroke (I61 series) 1, 4
Documentation Requirements
- Medical record should clearly document the embolic nature of the stroke for proper code assignment 1
- Neurological examination findings should quantify the extent of motor and sensory loss 3
- Documentation of functional status using modified Rankin Scale (mRS) between 30-90 days is recommended for optimal assessment of disability 3