ICD-10 Coding for Left Side Hemiparesis(I69.354)
Complete ICD-10-CM coding and documentation guide for Left Side Hemiparesis. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Left Side Hemiparesis
I69.3Primary Range
Sequelae of cerebral infarction
This range includes codes for conditions resulting from a previous cerebral infarction, such as hemiparesis.
Sequelae of nontraumatic intracerebral hemorrhage
Relevant for conditions resulting from nontraumatic hemorrhage, not primary for infarction-related hemiparesis.
Key Information: ICD-10 code for left side hemiparesis
Essential facts and insights about Left Side Hemiparesis
Primary ICD-10-CM Code for left side hemiparesis
Decision Criteria
clinical Criteria
- Confirmed cerebral infarction on imaging
documentation Criteria
- Documentation specifies 'residual left hemiparesis due to cerebral infarction'
Applicable To
- Left hemiparesis due to prior stroke
Clinical Validation Requirements
- MRI/CT confirming cerebral infarction
- Neurological exam showing left-sided weakness
Code-Specific Risks
- Incorrectly coding as acute stroke
- Failing to specify laterality or dominance
Coding Notes
- Ensure documentation specifies 'residual' and links hemiparesis to prior infarction.
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 Left Side Hemiparesis to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code I69.354.
Impact
Clinical: May lead to inappropriate treatment plans., Regulatory: Non-compliance with ICD-10 coding standards., Financial: Potential for denied claims or reduced reimbursement.
Mitigation Strategy
Always document side and dominance in clinical notes., Use templates to ensure completeness.
Impact
Reimbursement: Incorrect coding can lead to reduced reimbursement., Compliance: May result in non-compliance with coding guidelines., Data Quality: Affects the accuracy of patient records and data reporting.
Mitigation Strategy
Use I69.354 to accurately reflect residual hemiparesis.
Impact
Failure to document laterality and dominance can lead to audit findings.
Mitigation Strategy
Implement documentation templates that prompt for this information.
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 Side Hemiparesis, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Left Side Hemiparesis
Use these documentation templates to ensure complete and accurate documentation for Left Side Hemiparesis. These templates include all required elements for proper coding and billing.
Post-stroke follow-up
Specialty: NeurologyRequired Elements
- Chief complaint
- History of present illness
- Neurological examination
- Imaging results
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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