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If a physician documents “weakness” in the physical exam for extremities, is that considered enough support for a diagnosis of history of CVA with left hemiparesis for CMS Risk Adjustment?

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If a physician documents “weakness” in the physical exam for extremities, is that considered enough support for a diagnosis of history of CVA with left hemiparesis for CMS Risk Adjustment?

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A. Unless the physician states that the patient has hemiparesis due to/secondary to the CVA, it cannot be coded. CMS Risk Adjustment follows all coding rules and guidelines, including those in Coding Clinic.

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