ICD-10 Coding for CVA with Right Hemiplegia(I69.351)
Complete ICD-10-CM coding and documentation guide for CVA with Right 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 Right Hemiplegia
I69.3Primary Range
Sequelae of Cerebrovascular Disease
This range includes codes for conditions resulting from previous cerebrovascular accidents, such as hemiplegia.
Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits
Used when documenting a history of CVA without current deficits.
Key Information: ICD-10 code for CVA with right hemiplegia
Essential facts and insights about CVA with Right Hemiplegia
Primary ICD-10-CM Code for cva right hemiplegia
Decision Criteria
clinical Criteria
- Right-sided weakness linked to past CVA
documentation Criteria
- Dominance and laterality specified
Applicable To
- Right-sided hemiplegia due to past CVA
Excludes
- Acute cerebrovascular accident (I63.9)
Clinical Validation Requirements
- Neurological exam showing right-sided weakness
- Imaging confirming past cerebral infarction
Code-Specific Risks
- Incorrectly coding as acute CVA
- Failing to specify dominance
Coding Notes
- Ensure documentation specifies 'hemiparesis' or 'hemiplegia' and links it to a past CVA.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Personal history of TIA and cerebral infarction without residual deficits
Z86.73Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Muscle weakness (generalized)
M62.81Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting CVA with Right Hemiplegia to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code I69.351.
Impact
Clinical: May lead to underestimation of the patient's condition severity., Regulatory: Could result in coding audits and corrections., Financial: Potentially affects reimbursement rates.
Mitigation Strategy
Use specific terms like 'hemiparesis' or 'hemiplegia'.
Impact
Reimbursement: Incorrect coding can lead to significant reimbursement discrepancies., Compliance: May result in compliance issues during audits., Data Quality: Affects the accuracy of patient records and data quality.
Mitigation Strategy
Use sequelae codes like I69.351 for chronic conditions post-CVA.
Impact
Failure to document the dominant side can lead to incorrect coding.
Mitigation Strategy
Implement a checklist for dominance documentation in patient records.
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 Hemiplegia, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for CVA with Right Hemiplegia
Use these documentation templates to ensure complete and accurate documentation for CVA with Right Hemiplegia. These templates include all required elements for proper coding and billing.
Chronic Right Hemiparesis Post-CVA
Specialty: NeurologyRequired Elements
- Patient history
- Neurological exam findings
- Imaging results
- Functional status
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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