ICD-10 Coding for CVA with Right Hemiparesis(I69.351, Z86.73)
Complete ICD-10-CM coding and documentation guide for CVA with Right 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 Right Hemiparesis
I69.3-I69.4Primary Range
Sequelae of cerebrovascular disease
This range includes codes for conditions resulting from previous cerebrovascular accidents, such as hemiparesis.
Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits
Used when the patient has a history of CVA but no current deficits.
Code Comparison: When to Use Each Code
Compare key differences between these codes to ensure accurate selection
| Code | Description | When to Use | Key Documentation |
|---|---|---|---|
| I69.351 | Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side | Use for patients with residual right-sided weakness post-CVA, assuming right dominance unless otherwise specified. |
|
| Z86.73 | Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits | Use when the patient has a history of CVA but no current deficits. |
|
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 right hemiparesis
Essential facts and insights about CVA with Right Hemiparesis
Primary ICD-10-CM Codes for cva right hemiparesis
Decision Criteria
clinical Criteria
- Presence of right-sided weakness post-CVA
documentation Criteria
- Documentation of right dominance or assumption if not specified
Applicable To
- Right-sided hemiparesis due to previous stroke
Clinical Validation Requirements
- Imaging reports confirming cerebral infarction
- Physical exam findings of right-sided weakness
Code-Specific Risks
- Incorrectly coding acute stroke in outpatient settings
Coding Notes
- Ensure documentation specifies the link between hemiparesis and the prior CVA.
Z86.73 - Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits
Use when the patient has a history of CVA but no current deficits.
Applicable To
- History of stroke without current deficits
Excludes
- Current hemiparesis (I69.351)
Clinical Validation Requirements
- Patient history indicating resolved deficits
Coding Notes
Ensure no current deficits are documented.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting CVA with Right Hemiparesis to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code I69.351.
Impact
Clinical: Inaccurate patient records, Regulatory: Potential audit issues, Financial: Denied claims due to insufficient documentation
Mitigation Strategy
Always link deficits to CVA in documentation, Use specific phrases like 'due to CVA'
Impact
Reimbursement: Incorrect coding can lead to denied claims., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate patient records and statistics.
Mitigation Strategy
Use I69.351 for residual deficits post-discharge.
Impact
Using I63 codes in outpatient settings post-discharge.
Mitigation Strategy
Educate coders on proper use of I69 codes for sequelae.
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 Right Hemiparesis, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for CVA with Right Hemiparesis
Use these documentation templates to ensure complete and accurate documentation for CVA with Right Hemiparesis. These templates include all required elements for proper coding and billing.
Outpatient follow-up for CVA with right hemiparesis
Specialty: NeurologyRequired Elements
- Patient history
- Neurological exam
- Imaging results
- Assessment and plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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