ICD-10 Coding for Hemiplegia and Hemiparesis(I69.351, I69.354)
Complete ICD-10-CM coding and documentation guide for Hemiplegia and Hemiparesis. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Hemiplegia and Hemiparesis
I69.3Primary Range
Sequelae of cerebral infarction
This range includes codes for hemiplegia and hemiparesis as sequelae of cerebrovascular disease.
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 when documenting right-sided hemiparesis post-cerebral infarction in a right-handed patient. |
|
| I69.354 | Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side | Use when documenting left-sided hemiparesis post-cerebral infarction in a left-handed or ambidextrous patient. |
|
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 hemiplegia post-stroke
Essential facts and insights about Hemiplegia and Hemiparesis
Primary ICD-10-CM Codes for hemiplegia and hemiparesis
Decision Criteria
clinical Criteria
- Right-sided weakness linked to past stroke
documentation Criteria
- Specify dominance and link to past CVA
Applicable To
- Right-sided weakness due to past stroke
Excludes
- Acute stroke (I63.9)
Clinical Validation Requirements
- MRI showing old right MCA infarct
- Neurological exam showing right-sided weakness
Code-Specific Risks
- Incorrectly using acute stroke codes for resolved cases
Coding Notes
- Ensure documentation specifies laterality and dominance.
I69.354 - Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side
Use when documenting left-sided hemiparesis post-cerebral infarction in a left-handed or ambidextrous patient.
Applicable To
- Left-sided weakness due to past stroke
Excludes
- Acute stroke (I63.9)
Clinical Validation Requirements
- CT evidence of left parietal infarct
- Neurological exam documenting left-sided spasticity
Coding Notes
Ensure documentation specifies laterality and dominance.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Dysphagia
R13.11Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Hemiplegia and 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: Leads to undercoding of current conditions., Regulatory: May result in audit findings for inaccurate documentation., Financial: Loss of potential reimbursement due to lower RAF scores.
Mitigation Strategy
Always assess and document current deficits, Link deficits to past CVA
Impact
Reimbursement: Incorrect coding can lead to claim denials., Compliance: May trigger audits due to inappropriate code usage., Data Quality: Affects accuracy of patient records and risk adjustment.
Mitigation Strategy
Use I69 codes for sequelae of cerebrovascular disease.
Impact
Using acute stroke codes for resolved conditions.
Mitigation Strategy
Educate providers 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 Hemiplegia and Hemiparesis, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Hemiplegia and Hemiparesis
Use these documentation templates to ensure complete and accurate documentation for Hemiplegia and Hemiparesis. These templates include all required elements for proper coding and billing.
Neurology Follow-Up
Specialty: NeurologyRequired Elements
- Assessment of hemiparesis
- Link to past CVA
- Specify laterality and dominance
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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