ICD-10 Coding for Left Hemiplegia(I69.354)
Complete ICD-10-CM coding and documentation guide for Left Hemiplegia. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Left Hemiplegia
I69.3Primary Range
Sequelae of cerebrovascular disease
This range includes codes for hemiplegia and hemiparesis following cerebrovascular disease, specifically for residual effects.
Cerebral infarction
Used for acute cerebral infarction events, not typically used for residuals post-discharge.
Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits
Used only when there are no residual deficits from a past stroke.
Key Information: ICD-10 code for left hemiplegia
Essential facts and insights about Left Hemiplegia
Primary ICD-10-CM Code for left hemiplegia
Decision Criteria
clinical Criteria
- Imaging confirms right hemisphere infarct with left-sided weakness
documentation Criteria
- Documentation specifies non-dominant side
Applicable To
- Left-sided hemiplegia
- Left-sided hemiparesis
Clinical Validation Requirements
- Imaging reports (CT/MRI) confirming prior cerebral infarction
- Neurological exams showing motor deficits
- Documentation of timeline (residuals post-CVA)
Code-Specific Risks
- Incorrectly coding as dominant side without confirmation
- Using acute stroke codes post-discharge
Coding Notes
- Ensure documentation specifies non-dominant side and confirms residuals.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Cerebral infarction, unspecified
I63.9Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Personal history of TIA and cerebral infarction without residual deficits
Z86.73Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Left Hemiplegia to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code I69.354.
Impact
Clinical: Misrepresentation of patient's condition., Regulatory: Potential for audit discrepancies., Financial: Incorrect reimbursement rates.
Mitigation Strategy
Always confirm and document dominance., Use templates to ensure completeness.
Impact
Reimbursement: Incorrect coding can lead to denied claims., Compliance: Non-compliance with coding guidelines., Data Quality: Inaccurate patient records and risk adjustment.
Mitigation Strategy
Code I69.354 instead
Impact
Failure to specify can lead to incorrect coding.
Mitigation Strategy
Implement mandatory fields in EHR for laterality and dominance.
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 Left Hemiplegia, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Left Hemiplegia
Use these documentation templates to ensure complete and accurate documentation for Left Hemiplegia. These templates include all required elements for proper coding and billing.
Follow-up for chronic residuals
Specialty: NeurologyRequired Elements
- History of present illness
- Physical exam findings
- Assessment and plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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