ICD-10 Coding for CVA with Left Hemiplegia(I69.354)
Complete ICD-10-CM coding and documentation guide for CVA with Left Hemiplegia. 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 Hemiplegia
I69.3Primary Range
Sequelae of Cerebrovascular Disease
This range includes codes for conditions resulting from a previous cerebrovascular accident, including hemiplegia.
Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits
Used when there are no residual deficits from a past CVA.
Key Information: ICD-10 code for CVA with left hemiplegia
Essential facts and insights about CVA with Left Hemiplegia
Primary ICD-10-CM Code for cva left hemiplegia
Decision Criteria
clinical Criteria
- Presence of left hemiplegia due to past CVA
documentation Criteria
- Documentation specifies non-dominant side
Applicable To
- Residual left hemiplegia due to past CVA
Excludes
- Acute cerebrovascular accident (I63.9)
Clinical Validation Requirements
- Documentation of residual left hemiplegia due to past CVA
- Neurological exam findings showing motor deficits
- Imaging reports confirming left-sided infarction
Code-Specific Risks
- Incorrectly coding as acute CVA when the condition is a sequela
- Failing to document laterality and dominance
Coding Notes
- Ensure documentation specifies 'residual' and links hemiplegia to the past CVA.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Dysphasia
R47.02Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side
I69.351Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting CVA with Left Hemiplegia to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code I69.354.
Impact
Clinical: Leads to underreporting of current patient status., Regulatory: Non-compliance with coding guidelines., Financial: Potential for denied claims due to insufficient documentation.
Mitigation Strategy
Ensure documentation specifies current deficits, Use templates to guide documentation
Impact
Reimbursement: Incorrect use can lead to denied claims., Compliance: Non-compliance with ICD-10 guidelines., Data Quality: Inaccurate patient records and statistics.
Mitigation Strategy
Use I69 codes for sequelae with proper laterality and dominance.
Impact
High risk of audits if acute codes are used beyond the acute phase.
Mitigation Strategy
Use I69 codes for sequelae and ensure documentation supports code selection.
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 Hemiplegia, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for CVA with Left Hemiplegia
Use these documentation templates to ensure complete and accurate documentation for CVA with Left Hemiplegia. These templates include all required elements for proper coding and billing.
Outpatient follow-up for residual left hemiplegia
Specialty: NeurologyRequired Elements
- History of present illness
- Neurological exam findings
- Imaging results
- Treatment plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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