Spastic hemiplegia affecting left dominant side

This diagnosis code signifies a form of cerebral palsy or other neurological condition characterized by spasticity (increased muscle tone and stiffness) impacting one side of the body, specifically the left side. The affected left side is identified as the dominant side for the patient.

Apply this code when documentation clearly indicates spastic hemiplegia on the patient's left side, and the patient's medical record specifies that the left side is their dominant side. This is typically seen in patients with congenital or acquired brain injuries affecting motor control.

• Ensure documentation explicitly states "left dominant" to support the specificity of this code. If dominance is not specified, an unspecified dominance code should be used.
• Differentiate from flaccid hemiplegia or other forms of cerebral palsy; this code is specific to spasticity.
• Consider sequencing with underlying neurological conditions (e.g., cerebral infarction, traumatic brain injury) that may be the etiology of the hemiplegia.