ICD-10 Coding for Hemiplegia(I69.351, I69.354)
Complete ICD-10-CM coding and documentation guide for Hemiplegia. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Hemiplegia
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 residual hemiplegia on the right dominant side following a cerebral infarction. |
|
| I69.354 | Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side | Use for residual hemiplegia on the left non-dominant side following a 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 hemiplegia
Essential facts and insights about Hemiplegia
Primary ICD-10-CM Codes for hemiplegia
Decision Criteria
documentation Criteria
- Document the affected side and dominance clearly.
Applicable To
- Right dominant hemiplegia post-stroke
Excludes
- Acute stroke (I63.9)
Clinical Validation Requirements
- Documentation of right-sided weakness post-CVA
- Confirmation of right side as dominant
Code-Specific Risks
- Incorrectly coding as acute stroke post-discharge
Coding Notes
- Ensure documentation specifies the affected side and dominance.
I69.354 - Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side
Use for residual hemiplegia on the left non-dominant side following a cerebral infarction.
Applicable To
- Left non-dominant hemiplegia post-stroke
Excludes
- Acute stroke (I63.9)
Clinical Validation Requirements
- Documentation of left-sided weakness post-CVA
- Confirmation of left side as non-dominant
Coding Notes
Default to non-dominant for left side unless specified otherwise.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Differential 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 to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code I69.351.
Impact
Clinical: Inadequate treatment planning., Regulatory: Non-compliance with coding standards., Financial: Potential for claim denials.
Mitigation Strategy
Always document residual deficits post-stroke., Use I69 codes for sequelae.
Impact
Reimbursement: Incorrect coding can lead to denied claims., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate patient records.
Mitigation Strategy
Switch to I69 codes for residual effects post-discharge.
Impact
Reimbursement: Potential for incorrect DRG assignment., Compliance: Failure to meet documentation standards., Data Quality: Incomplete clinical data.
Mitigation Strategy
Document and code the dominance of the affected side.
Impact
Failure to document dominance can lead to incorrect coding.
Mitigation Strategy
Implement mandatory fields for dominance 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 Hemiplegia, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Hemiplegia
Use these documentation templates to ensure complete and accurate documentation for Hemiplegia. These templates include all required elements for proper coding and billing.
Post-stroke follow-up
Specialty: NeurologyRequired Elements
- History of present illness detailing stroke and residuals
- Physical exam findings including strength and reflexes
- Plan for ongoing management and rehabilitation
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
Need help with ICD-10 coding for Hemiplegia? Ask your questions below.