ICD-10 Coding for CVA with Left Hemiparesis(I69.354)
Complete ICD-10-CM coding and documentation guide for CVA with Left Hemiparesis. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to CVA with Left Hemiparesis
I69.3-I69.35Primary Range
Sequelae of Cerebral Infarction
This range includes codes for conditions resulting from a previous cerebral infarction, such as hemiparesis.
Key Information: ICD-10 code for CVA with left hemiparesis
Essential facts and insights about CVA with Left Hemiparesis
Primary ICD-10-CM Code for cva left hemiparesis
Decision Criteria
clinical Criteria
- Documented left-sided weakness with past CVA
coding Criteria
- Avoid using acute CVA codes in outpatient settings
Applicable To
- Residual left-sided weakness due to past CVA
Excludes
- Acute CVA (I63.x)
Clinical Validation Requirements
- Neurological exam confirming left-sided weakness
- Imaging (CT/MRI) showing past infarct
Code-Specific Risks
- Incorrectly coding as acute CVA in outpatient settings
Coding Notes
- Ensure documentation clearly links hemiparesis to the past CVA.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Hemiplegia/hemiparesis following cerebral infarction affecting right dominant side
I69.351Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting CVA with Left Hemiparesis to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code I69.354.
Impact
Clinical: May lead to mismanagement of ongoing deficits., Regulatory: Fails to meet documentation standards., Financial: Potential for claim denials.
Mitigation Strategy
Always include current neurological exam findings, Link deficits to past CVA
Impact
Reimbursement: Incorrect coding can lead to denied claims., Compliance: Non-compliance with ICD-10 guidelines., Data Quality: Inaccurate patient records.
Mitigation Strategy
Use sequela codes (I69.x) for outpatient documentation of past CVA effects.
Impact
Using I63.x codes in outpatient settings for past CVA sequelae.
Mitigation Strategy
Educate staff on proper use of sequela codes.
Documentation errors, coding pitfalls, and audit risks are interconnected aspects of medical coding and billing. Addressing all three areas helps ensure accurate coding, optimal reimbursement, and regulatory compliance.
Frequently Asked Questions
Common questions about ICD-10 coding for CVA with Left Hemiparesis, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for CVA with Left Hemiparesis
Use these documentation templates to ensure complete and accurate documentation for CVA with Left Hemiparesis. These templates include all required elements for proper coding and billing.
Follow-up visit for CVA with left hemiparesis
Specialty: NeurologyRequired Elements
- History of present illness
- Neurological exam findings
- Assessment linking hemiparesis to past CVA
- Treatment plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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