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Outpatient Facility Coding Alert

You Be the Coder:

Refer to ICD-10-CM Guidelines for Monoplegia, Hemiplegia Coding

Question: Should I code a patient with monoplegia of the left arm as G83.22 or G83.20?

Delaware Subscriber

Answer: ICD-10-CM guidelines for coding monoplegia and hemiplegia state that, “should the affected side be documented, but not specified as dominant or nondominant, and the classification system does not indicate a default, code selection is as follows:

  • For ambidextrous patients, the default should be dominant.
  • If the left side is affected, the default is non-dominant.
  • If the right side is affected, the default is dominant.”

This means that, when the documentation specifies left or right side, you should never use code G83.20 (Monoplegia of upper limb affecting unspecified side). Additionally, you should not conclude that the left side is dominant without documentation stating so. Therefore, G83.22 (Monoplegia of upper limb affecting left dominant side) would also be incorrect in this example. Since the left arm is documented, but there is no indication of dominant versus non-dominant sides, you should refer to the guidelines above.

By default, you should report left-sided monoplegia without specification of dominance as non-dominant under code G83.24 (Monoplegia of upper limb affecting left nondominant side).