ICD-10 Coding for Right Hemiparesis(I69.351)
Complete ICD-10-CM coding and documentation guide for Right Hemiparesis. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Right Hemiparesis
I69.3Primary Range
Sequelae of cerebral infarction
This range includes codes for hemiparesis following cerebral infarction, specifying laterality and dominance.
Cerebral infarction
Used for acute cerebral infarction, which may be coded alongside sequelae codes if the infarction is recent.
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 right hemiparesis
Essential facts and insights about Right Hemiparesis
Primary ICD-10-CM Code for right hemiparesis
Decision Criteria
clinical Criteria
- Right-sided weakness post-CVA with imaging confirmation
documentation Criteria
- Documentation specifies 'right dominant' and links to CVA
Applicable To
- Right dominant hemiparesis post-CVA
Excludes
- Congenital hemiplegia (G81.0)
Clinical Validation Requirements
- Imaging (CT/MRI) showing old infarct
- Neuro exam indicating right-sided weakness
- Documentation of dominance
Code-Specific Risks
- Incorrectly defaulting to non-dominant side
Coding Notes
- Ensure documentation specifies 'right dominant' and links to cerebral infarction.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
History of CVA without residuals
Z86.73Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Right 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 incorrect treatment assumptions., Regulatory: Non-compliance with ICD-10 guidelines., Financial: Affects reimbursement and RAF scoring.
Mitigation Strategy
Always document dominance in hemiparesis cases.
Impact
Reimbursement: Incorrect dominance affects DRG and RAF scoring., Compliance: Non-compliance with ICD-10 guidelines., Data Quality: Inaccurate patient records and data reporting.
Mitigation Strategy
Default to right=dominant unless specified otherwise.
Impact
Failure to document dominance can lead to audit findings.
Mitigation Strategy
Educate providers on importance of documenting 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 Right Hemiparesis, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Right Hemiparesis
Use these documentation templates to ensure complete and accurate documentation for Right Hemiparesis. These templates include all required elements for proper coding and billing.
Follow-up visit for right hemiparesis post-CVA
Specialty: NeurologyRequired Elements
- Dominance
- Link to CVA
- Neuro exam findings
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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