A neurology clinic follow-up documents hemiplegia as a sequela of prior CVA, including affected side and dominance when known. What coding concept applies?
Select an answer to reveal the explanation.
Short Explanation
Old stroke, lasting weakness—that’s sequela territory, not a fresh stroke code every visit. Hemiplegia wants side (and dominance when the note gives it). Capture the residual neuro deficit the way the documentation describes it.
Full Explanation
Late effects of cerebrovascular disease are coded with sequela pathways rather than acute stroke codes when the encounter addresses residual conditions. Hemiplegia following CVA includes laterality and, when documented, dominance characters per category structure. Personal history of CVA alone does not describe ongoing hemiplegia residuals. Coders should not report acute cerebral infarction for routine sequela follow-up without documentation of a new acute event.