Our nurse documented "s/p CVA with right-sided muscle weakness"
According to the referral and the face-to-face documentation, the patient was being evaluated for a TIA/CVA but the imaging studies revealed NO evidence of an infarct. It repeatedly mentioned having "right-sided weakness" but the word "hemiplegia" was never specifically mentioned. Can you code "hemiplegia uns. affecting right dominant side" to capture the laterality? Or does it stick to basic "muscle weakness"??