Cerebral Palsy: Documenting Motor Type, Severity, and Coding Impact

Definition: Cerebral palsy (CP) describes a group of heterogeneous conditions that have lifelong impact on motor function, muscle tone, posture, and movement. This is due to the improper development of the fetal or infant brain. Motor function deficits can range in severity and are commonly accompanied by altered sensation, intellectual disability, seizures, and musculoskeletal complications. 

Clinical Features and Indicators of Cerebral Palsy

Common Motor Function Features: 

• Muscle spasticity 
• Hyperreflexia 
• Clonus 
• Hypotonia 
• Ataxia 

Common Clinical Indicators: 

• Abnormalities in motor activity and tone 
• Delay in meeting developmental motor milestones 
• Abnormal developmental reflexes 
• Feeding difficulty 
• Growth failure 
• Epilepsy 

Cerebral Palsy Motor Phenotypes

Common motor phenotypes: 

• Spastic CP - Most common pattern of motor impairment, accounting for up to 85 percent of individuals with CP. These patients have clinical features of an upper motor neuron syndrome, including muscle hypertonia, hyperreflexia, extensor plantar responses, and clonus. 
• Dyskinetic CP - Indicates that dyskinesia such as dystonia or choreoathetosis (e.g., involuntary twitching) is the predominant pattern of abnormal tone. 
• Ataxic CP - Characterized by uncoordinated movements and speech, usually associated with widespread disorder of motor function. This type is rare. 

ICD-10-CM Coding for Cerebral Palsy

CDI Documentation and Query Considerations

Thoughts for the CDI Professional 

• Intellectual disability is common in children with CP, 40-65%. 
• Documentation should indicate the degree of weakness or paralysis associated with CP and any intellectual disability with severity specified. 

Sample CDI Query for Cerebral Palsy Specificity

Query Example: 

Dr. _________ 

This patient has documentation and findings for cerebral palsy in the H&P from x/x. 

Based on review of the clinical indicators presented, can this information be further specified? For example: 

• Spastic hemiplegic cerebral palsy 
• Other explanation of clinical findings (please specificity) 

Additional supporting information from patient’s record: 

Clinical Indicators: 

• Physical Exam notes left sided spasticity and increased tone and thin left upper extremity likely related to limitation of use. 

Risk Factors: 

• Patient with neonatal asphyxia at birth 

Monitoring/Evaluation and/or Treatment: 

• Continuation of PTA Baclofen 
• Recent injection of Botulinum toxin 
• PT/OT consult ordered 

Thank you! 

 -CDI Specialist signature 

Please use your independent professional judgment when responding. A question does not imply that a particular diagnosis is expected. Please update your last progress note and/or discharge summary to include the relevant diagnosis.   

This query will become part of the patient’s permanent medical record. 



Alyce Reavis, RN, MSN, CCDS, CCS 

Senior CDI Educator, Consulting Services at UASI

Drawing on clinical experience in adult, pediatric, and neonatal acute care, Alyce brings valuable insight to CDI education and documentation improvement. She holds an MSN in Leadership/Education along with CCDS, CCS, and AHIMA’s outpatient CDI micro credential, supporting health systems in strengthening documentation accuracy, quality reporting, and reimbursement integrity. Passionate about truthful, clinically aligned health records, she helps organizations ensure documentation reflects true patient acuity. She is a past presenter for the ACDIS National Convention, Local chapter meetings, and the ACDIS Virtual Best Practices conference. 

Works Cited

Barkouda, E. (2025–2026). Cerebral palsy: Classification, clinical features, management, and prognosis. UpToDate. Available at: https://www.uptodate.com

Centers for Medicare & Medicaid Services. (2026). IPPS Final Rule. Available at: https://www.cms.gov

Pinson, R., & Tang, C. (2025). Cerebral palsy. Pediatrics by PRG from the CDI Pocket Guide. CDIPlus.