AHA Coding Clinic® for ICD-10-CM and ICD-10-PCS - 2015 Issue 1; Ask the Editor

Acute Cerebral Infarction with Left-Sided Weakness

An 88-year-old male patient is admitted secondary to a cerebral infarction. In the final diagnostic statement, the provider documented “acute cerebral infarction involving the right hemisphere with left-sided (nondominant) weakness.” How should left-sided weakness due to an acute cerebral infarction be coded when there is no specific mention of hemiplegia/hemiparesis? ...

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