Answer :
Final answer:
The ICD-10 code for a cerebrovascular accident (CVA) with left side weakness is not explicitly defined, as it depends on the specific details of the stroke and its effects. Initial general code could be 'I64,' and specific coding would require a complete diagnostic assessment.
Explanation:
ICD-10 Code for CVA with Left Side Weakness
The ICD-10 code for a cerebrovascular accident (CVA) with left side weakness would typically fall under the category of codes related to stroke, depending on other clinical details provided. The term “CVA with left side weakness” could correspond to the ICD-10 code “I64” for Stroke, not specified as haemorrhage or infarction, if the cause of the stroke is not specified within the documentation. However, once a CT scan is performed and more details are known, specific codes such as those for “Ischemic stroke” might be used, like “I63” followed by additional characters that specify the affected artery or type of infarct. If the patient exhibits immediate left-sided weakness after the stroke, a code from the I69 series which denotes sequela of cerebrovascular disease might be appropriate, again depending on further detail provided, such as the presence of hemiplegia.
When a patient is experiencing left side weakness after a CVA, this typically indicates a right-brain injury and might require a specific diagnosis code that reflects the side and the specific deficits (sensory or motor). Therefore, a detailed neurological exam and diagnostic imaging are critical components to an accurate diagnosis and hence an accurate ICD-10 coding.
Care should be taken to follow the guidelines for coding the conditions accurately, which might require additional codes to fully capture the specific clinical picture, including any complications like difficulty in swallowing (dysphagia) or sensory deficits, as suggested by the patient's reported pins and needles sensation.
