For PM&R, when the condition is not documented as a sequela of stroke/CVA, you generally use the symptom, functional, neurologic, and impairment codes below.
Gait / Mobility R26.0 - Ataxic gait R26.1 - Paralytic gait R26.2 - Difficulty in walking, not elsewhere classified R26.81 - Unsteadiness on feet R26.89 - Other abnormalities of gait and mobility Z74.09 - Other reduced mobility Z99.3 - Dependence on wheelchair Weakness / Debility R53.1 - Weakness R53.81 - Physical debility R53.83 - Other fatigue M62.81 - Muscle weakness (generalized) M62.838 - Other muscle spasm R29.898 - Other symptoms involving the musculoskeletal system Falls / Balance R29.6 - Repeated falls Z91.81 - History of falling R27.0 - Ataxia, unspecified R27.8 - Other lack of coordination R26.81 - Unsteadiness on feet Cognitive Deficits R41.3 - Other amnesia (memory loss) R41.840 - Attention and concentration deficit R41.841 - Cognitive communication deficit R41.842 - Visuospatial deficit R41.843 - Psychomotor deficit R41.844 - Frontal lobe and executive function deficit R41.89 - Other symptoms involving cognitive functions and awareness
Continued- Speech / Language / Swallow (Not linked to stroke) R47.01 - Aphasia R47.02 - Dysphasia R47.1 - Dysarthria and anarthria R47.81 - Slurred speech R47.89 - Other speech disturbances R48.2 - Apraxia R13.10 - Dysphagia, unspecified R13.11 - Dysphagia, oral phase R13.12 - Oropharyngeal dysphagia R13.13 - Pharyngeal dysphagia R13.14 - Pharyngoesophageal dysphagia Neurologic Disorders G20.A1 - Parkinson disease without dyskinesia, without fluctuations G20.A2 - Parkinson disease without dyskinesia, with fluctuations G20.B1 - Parkinson disease with dyskinesia, without fluctuations G20.B2 - Parkinson disease with dyskinesia, with fluctuations G35 - Multiple sclerosis G62.9 - Polyneuropathy, unspecified G62.0 - Drug-induced polyneuropathy G62.1 - Alcoholic polyneuropathy G62.89 - Other specified polyneuropathies G12.21 - Amyotrophic lateral sclerosis G61.0 - Guillain-Barré syndrome Neurogenic Bowel / Bladder N31.9 - Neuromuscular dysfunction of bladder, unspecified N31.8 - Other neuromuscular dysfunction of bladder K59.2 - Neurogenic bowel, not elsewhere classified R32 - Urinary incontinence, unspecified R15.9 - Full incontinence of feces Pain Diagnoses G89.4 - Chronic pain syndrome G89.21 - Chronic pain due to trauma G89.28 - Other chronic postprocedural pain G89.29 - Other chronic pain Sequela Think of sequela as: “The problem that is left over after the original injury or disease is finished.” .Sequela (Late Effects) A sequela is the residual effect (condition produced) after the acute phase of an illness or injury has terminated. There is no time limit on when a sequela code can be used. The residual may be apparent early, such as in cerebral infarction, or it may occur months or years later, such as that due to a previous injury. Examples of sequela include: scar formation resulting from a burn, deviated septum due to a nasal fracture, and infertility due to tubal occlusion from old tuberculosis. Coding of sequela generally requires two codes sequenced in the following order: the condition or nature of the sequela is sequenced first. The sequela code is sequenced second. ” Attention and concentration deficit due to prior TBI.” Codes: R41.840 - Attention and concentration deficit (Code Residual first) S06.9X9S - Unspecified intracranial injury with loss of consciousness of unspecified duration, sequela (Code TBI second) Why: The accident is over. You are treating the leftover problems (memory and attention issues). Traumatic Brain Injury (TBI) Sequela Used when the brain injury is old and the patient has lasting problems. Examples: S06.9X9S - Unspecified intracranial injury with loss of consciousness of unspecified duration, sequela S06.5X9S - Traumatic subdural hemorrhage, sequela S06.6X9S - Traumatic subarachnoid hemorrhage, sequela Spinal Cord Injury Sequela For traumatic SCI: S14.-XS - Cervical spinal cord injury, sequela S24.-XS - Thoracic spinal cord injury, sequela S34.-XS - Lumbar spinal cord injury, sequela Use I69 only for residual deficits from a prior stroke: → Code I69. ✅ Examples: Right hemiparesis due to old CVA Aphasia due to prior stroke Dysphagia from previous infarct Cognitive deficits after stroke Provider documentation examples: “Residual right hemiparesis from prior CVA” “Late effects of stroke” “Chronic aphasia following ischemic stroke” “History of hemorrhagic stroke with residual dysphagia” Do NOT use I69 for an acute stroke: If the patient is still being treated for the acute stroke, code: I63.- Cerebral infarction I61.- Intracerebral hemorrhage I60.- Subarachnoid hemorrhage NOT I69 Dysphasia following I69.021: Dysphasia following nontraumatic subarachnoid hemorrhage I69.121: Dysphasia following nontraumatic intracerebral hemorrhage I69.221: Dysphasia following other nontraumatic intracranial hemorrhage I69.321: Dysphasia following cerebral infarction I69.821: Dysphasia following other cerebrovascular disease I69.921: Dysphasia following unspecified cerebrovascular disease Dysphagia following I69.091: Dysphagia following nontraumatic subarachnoid hemorrhage I69.191: Dysphagia following nontraumatic intracerebral hemorrhage I69.291: Dysphagia following other nontraumatic intracranial hemorrhage I69.391: Dysphagia following cerebral infarction I69.891: Dysphagia following other cerebrovascular disease I69.991: Dysphagia following unspecified cerebrovascular disease Facial weakness following I69.092: Facial weakness following nontraumatic subarachnoid hemorrhage I69.192: Facial weakness following nontraumatic intracerebral hemorrhage I69.292: Facial weakness following other nontraumatic intracranial hemorrhage I69.392: Facial weakness following cerebral infarction I69.892: Facial weakness following other cerebrovascular disease I69.992: Facial weakness following unspecified cerebrovascular disease Ataxia following I69.093: Ataxia following nontraumatic subarachnoid hemorrhage I69.193: Ataxia following nontraumatic intracerebral hemorrhage I69.293: Ataxia following other nontraumatic intracranial hemorrhage I69.393: Ataxia following cerebral infarction I69.893: Ataxia following other cerebrovascular disease I69.993: Ataxia following unspecified cerebrovascular disease Attention and concentration deficit following I69.010: Attention and concentration deficit following nontraumatic subarachnoid hemorrhage I69.110: Attention and concentration deficit following nontraumatic intracerebral hemorrhage I69.210: Attention and concentration deficit following other nontraumatic intracranial hemorrhage I69.310: Attention and concentration deficit following cerebral infarction I69.810: Attention and concentration deficit following other cerebrovascular disease I69.910: Attention and concentration deficit following unspecified cerebrovascular disease Memory deficit following I69.011: Memory deficit following nontraumatic subarachnoid hemorrhage I69.111: Memory deficit following nontraumatic intracerebral hemorrhage I69.211: Memory deficit following other nontraumatic intracranial hemorrhage I69.311: Memory deficit following cerebral infarction I69.811: Memory deficit following other cerebrovascular disease I69.911: Memory deficit following unspecified cerebrovascular disease Cognitive social or emotional deficit following I69.015: Cognitive social or emotional deficit following nontraumatic subarachnoid hemorrhage I69.115: Cognitive social or emotional deficit following nontraumatic intracerebral hemorrhage I69.215: Cognitive social or emotional deficit following other nontraumatic intracranial hemorrhage I69.315: Cognitive social or emotional deficit following cerebral infarction I69.815: Cognitive social or emotional deficit following other cerebrovascular disease I69.915: Cognitive social or emotional deficit following unspecified cerebrovascular disease Other cognitive deficits following I69.018: Other cognitive deficits following nontraumatic subarachnoid hemorrhage I69.118: Other cognitive deficits following nontraumatic intracerebral hemorrhage I69.218: Other cognitive deficits following other nontraumatic intracranial hemorrhage I69.318: Other cognitive deficits following cerebral infarction I69.818: Other cognitive deficits following other cerebrovascular disease I69.918: Other cognitive deficits following unspecified cerebrovascular disease Aphasia following I69.020: Aphasia following nontraumatic subarachnoid hemorrhage I69.120: Aphasia following nontraumatic intracerebral hemorrhage I69.220: Aphasia following other nontraumatic intracranial hemorrhage I69.320: Aphasia following cerebral infarction I69.820: Aphasia following other cerebrovascular disease I69.920: Aphasia following unspecified cerebrovascular disease
Do not use G81/G82 codes for deficits due to a prior stroke. IF the hemiplegia/paraplegia is documented as a sequela of a CVA, the I69.35x or I69.36x codes should be used instead. The G81/G82 codes are for non-cerebrovascular causes (e.g., TBI, brain tumor, spinal cord injury, cerebral palsy, etc.).
Hemiplegia (Non-cerebrovascular) G81.90 - Hemiplegia, unspecified affecting unspecified side G81.91 - Hemiplegia affecting right dominant side G81.92 - Hemiplegia affecting left dominant side G81.93 - Hemiplegia affecting right nondominant side G81.94 - Hemiplegia affecting left nondominant side Paraplegia G82.20 - Paraplegia, unspecified G82.21 - Complete paraplegia G82.22 - Incomplete paraplegia Quadriplegia (Tetraplegia) G82.50 - Quadriplegia, unspecified G82.51 - Complete quadriplegia G82.52 - Incomplete quadriplegia Other Paralytic Syndromes G83.4 - Cauda equina syndrome G83.9 - Paralytic syndrome, unspecified Multiple Sclerosis G35 - Multiple sclerosis