NIHSS score 41

This code indicates a National Institutes of Health Stroke Scale (NIHSS) score of 41, representing the most severe end of the scale. An NIHSS score of 41 signifies profound neurological deficit, typically associated with a massive and devastating acute ischemic stroke. Patients with this score often present with severe impairment across multiple neurological domains, including consciousness, motor function, sensation, and language.

Use this code when documentation explicitly states an NIHSS score of 41 following an acute stroke event. This score is typically assessed by trained medical professionals in the emergency department or acute care setting. Documentation should clearly reflect the comprehensive neurological examination findings that support this specific, highest possible NIHSS score.

• Always ensure the medical record explicitly documents "NIHSS score 41" or provides a detailed breakdown of individual NIHSS components that sum to 41.
• This code is a secondary diagnosis and should be sequenced after the primary diagnosis for the acute stroke (e.g., I63.x for ischemic stroke).
• Do not assign this code if the NIHSS score is not explicitly documented or if the documented score is anything other than 41.