I4900: Hemiplegia or Hemiparesis, Step-by-Step

Step-by-Step Coding Guide for Item Set I4900: Hemiplegia or Hemiparesis

1. Review of Medical Records

• Objective: To determine if the resident has a diagnosis of hemiplegia or hemiparesis.
• Process:
  • Diagnosis Records: Review the resident’s medical history for a documented diagnosis of hemiplegia or hemiparesis.
  • Physician Notes: Examine notes from neurologists and other physicians detailing the diagnosis and related symptoms.
  • Therapy Notes: Check physical and occupational therapy notes for assessments related to hemiplegia or hemiparesis.
  • Radiology Reports: Review imaging reports, such as MRI or CT scans, that support the diagnosis.

2. Understanding Definitions

• Hemiplegia: Total paralysis of one side of the body, typically resulting from a brain injury or stroke.
• Hemiparesis: Weakness or partial paralysis affecting one side of the body, often due to similar causes as hemiplegia.

3. Coding Instructions

• Code I4900:
  • 0: No, the resident does not have hemiplegia or hemiparesis.
  • 1: Yes, the resident has hemiplegia or hemiparesis.
• Example: If the resident has a documented diagnosis of left-sided hemiparesis following a stroke, code I4900 as '1'.

4. Coding Tips

• Confirm Diagnosis: Ensure that the diagnosis is confirmed by a physician and supported by medical documentation.
• Active Diagnosis: Verify that the condition is currently affecting the resident’s health status, not just a historical diagnosis.

5. Documentation

• Required Documentation:
  • Physician Notes: Detailed notes confirming the diagnosis of hemiplegia or hemiparesis.
  • Therapy Records: Documentation from physical or occupational therapy sessions indicating the impact of the condition.
  • Diagnostic Reports: MRI, CT scans, or other imaging reports supporting the diagnosis.
• Example: "On 05/10/2024, the resident was diagnosed with right-sided hemiplegia following a stroke. This is documented in the neurologist’s report and supported by an MRI scan."

6. Common Errors to Avoid

• Misclassification: Coding for hemiplegia or hemiparesis without confirmed diagnosis.
• Outdated Records: Using old medical records without confirming the current status of the condition.
• Incomplete Documentation: Failing to document all relevant details and supporting evidence of the diagnosis.

7. Practical Application

• Scenario: A resident with a history of stroke exhibits significant weakness on one side of the body. The physician’s notes confirm a diagnosis of hemiparesis, and therapy notes indicate ongoing rehabilitation efforts. This consistent and thorough documentation leads to coding I4900 as '1'.

Please note that the information provided in this guide for MDS 3.0 Item set I4900 was originally based on the CMS's RAI Version 3.0 Manual, October 2023 edition. Every effort will be made to update it to the most current version. The MDS 3.0 Manual is typically updated every October. If there are no changes to the Item Set, there will be no changes to this guide. This guidance is intended to assist healthcare professionals, particularly new nurses or MDS coordinators, in understanding and applying the correct coding procedures for this specific item within MDS 3.0. 

The guide is not a substitute for professional judgment or the facility’s policies. It is crucial to stay updated with any changes or updates in the MDS 3.0 manual or relevant CMS regulations. The guide does not cover all potential scenarios and should not be used as a sole resource for MDS 3.0 coding. 

Additionally, this guide refrains from handling personal patient data and does not provide medical or legal advice. Users are responsible for ensuring compliance with all applicable laws and regulations in their respective practices.