Spastic hemiplegia affecting unspecified side

This code signifies a form of cerebral palsy characterized by increased muscle tone and stiffness (spasticity) affecting one side of the body, without specifying whether it's the left or right side. It results in impaired motor function and movement on the affected side.

Apply this code when documentation clearly indicates spastic hemiplegia but does not specify the laterality (left or right side). This is appropriate for initial assessments or when the specific side is not yet determined or recorded.

• Avoid using this code if the medical record specifies the affected side; instead, use the more specific G81.11 (right) or G81.12 (left).
• Always query the provider for laterality if not documented, as more specific codes offer better data for patient care and reimbursement.
• Consider sequencing this code after any underlying cause of the hemiplegia, if known and documented.