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ICD-10 Coding for CVA with Left-Sided Weakness(I69.354, I69.352)

Complete ICD-10-CM coding and documentation guide for CVA with Left-Sided Weakness. Includes clinical validation requirements, documentation requirements, and coding pitfalls.

Also known as:

Left Hemiparesis Post-CVALeft-Sided Weakness Due to Stroke

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Related ICD-10 Code Ranges

Complete code families applicable to CVA with Left-Sided Weakness

I69.35-I69.39Primary Range

Sequelae of Cerebrovascular Disease

This range includes codes for hemiplegia and hemiparesis following a cerebrovascular accident, specifying laterality and dominance.

I60-I67

Cerebrovascular Diseases

These codes are used for acute cerebrovascular events and may be used alongside sequelae codes during active treatment.

Code Comparison: When to Use Each Code

Compare key differences between these codes to ensure accurate selection

CodeDescriptionWhen to UseKey Documentation
I69.354Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant sideUse when left-sided weakness is documented as a sequela of a past CVA in a right-handed patient.
  • Clinical documentation linking left-sided weakness to a past CVA
  • Imaging evidence of right-sided cerebral infarction
I69.352Hemiplegia and hemiparesis following cerebral infarction affecting left dominant sideUse when left-sided weakness is documented as a sequela of a past CVA in a left-handed or ambidextrous patient.
  • Clinical documentation linking left-sided weakness to a past CVA
  • Imaging evidence of right-sided cerebral infarction

Clinical Decision Support

Always review the patient's clinical documentation thoroughly. When in doubt, choose the more specific code and ensure documentation supports it.

Key Information: ICD-10 code for CVA with left-sided weakness

Essential facts and insights about CVA with Left-Sided Weakness

The ICD-10 code for CVA with left-sided weakness in a right-handed patient is I69.354, indicating hemiparesis affecting the left non-dominant side.

Primary ICD-10-CM Codes for cva left sided weakness

I69.354
Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side
Billable Code

Decision Criteria

clinical Criteria

  • Patient exhibits left-sided weakness following a documented CVA.

documentation Criteria

  • Documentation must specify the CVA's impact on the left side and patient handedness.

Applicable To

  • Left-sided weakness post-CVA in right-handed patients

Excludes

  • Acute CVA without residuals

Clinical Validation Requirements

  • Clinical documentation linking left-sided weakness to a past CVA
  • Imaging evidence of right-sided cerebral infarction

Code-Specific Risks

  • Incorrectly coding as general weakness (M62.81) instead of hemiparesis

Coding Notes

  • Ensure documentation specifies the link between CVA and left-sided weakness, and confirm patient handedness.
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Ancillary Codes

Additional codes that should be used in conjunction with the main diagnosis codes when applicable.

Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits

Z86.73
Use when documenting a history of CVA without current residuals.

Differential Codes

Alternative codes to consider when ruling out similar conditions to the primary diagnosis.

Muscle weakness (generalized)

M62.81
Use M62.81 for generalized weakness not linked to a specific neurological event like CVA.

Documentation & Coding Risks

Avoid these common documentation and coding issues when documenting CVA with Left-Sided Weakness to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code I69.354.

Impact

Clinical: Potential misclassification of dominance, Regulatory: Non-compliance with coding specificity, Financial: Incorrect risk adjustment factor calculation

Mitigation Strategy

Always document patient handedness, Use templates that prompt for this information

Impact

Reimbursement: Potential loss of HCC-related reimbursement., Compliance: Non-compliance with coding guidelines for sequelae of CVA., Data Quality: Inaccurate representation of patient condition in medical records.

Mitigation Strategy

Ensure documentation specifies the link to CVA and laterality.

Impact

Failure to document patient handedness can lead to incorrect coding.

Mitigation Strategy

Implement mandatory fields for handedness in EMR templates.

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-Sided Weakness, with expert answers to help guide accurate code selection and documentation.

Documentation Templates for CVA with Left-Sided Weakness

Use these documentation templates to ensure complete and accurate documentation for CVA with Left-Sided Weakness. These templates include all required elements for proper coding and billing.

Chronic left-sided weakness post-CVA in a right-handed patient

Specialty: Neurology

Required Elements

  • Link to past CVA
  • Laterality and dominance
  • Imaging evidence

Example Documentation

Assessment: Residual left hemiparesis secondary to 2023 right MCA infarction in right-handed patient.

Examples: Poor vs. Good Documentation

Poor Documentation Example
History of CVA with left side weakness.
Good Documentation Example
Residual left hemiparesis secondary to 2023 right MCA infarction in right-handed patient.
Explanation
The good example specifies the link to CVA, laterality, and patient handedness.

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