ICD-10 Coding for Right Hemiplegia(I69.351)
Complete ICD-10-CM coding and documentation guide for Right Hemiplegia. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Right Hemiplegia
I69.3Primary Range
Sequelae of cerebrovascular disease
This range includes codes for conditions resulting from previous cerebrovascular events, such as strokes, that have residual effects like hemiplegia.
Key Information: ICD-10 code for right hemiplegia
Essential facts and insights about Right Hemiplegia
Primary ICD-10-CM Code for right hemiplegia
Decision Criteria
clinical Criteria
- Confirmed cerebral infarction on imaging
documentation Criteria
- Documentation of right side as dominant
Applicable To
- Right-sided paralysis due to past stroke
Excludes
- Acute cerebrovascular disease (I60-I67)
Clinical Validation Requirements
- Imaging (CT/MRI) confirming left hemisphere infarction
- Neurological exam showing motor deficits on the right side
- Documentation of right side as dominant
Code-Specific Risks
- Misclassification if dominance is not documented
- Incorrect use with acute stroke codes
Coding Notes
- Ensure documentation specifies the link between the hemiplegia and the previous stroke, including laterality and dominance.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits
Z86.73Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Hemiplegia, unspecified affecting right side
G81.91Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Right 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: Inaccurate representation of patient's condition., Regulatory: Potential audit trigger., Financial: Risk of claim denial.
Mitigation Strategy
Always document the patient's dominant side., Use templates that prompt for this information.
Impact
Reimbursement: Incorrect coding can lead to denied claims., Compliance: Non-compliance with ICD-10 guidelines., Data Quality: Inaccurate patient records and data reporting.
Mitigation Strategy
Use I69.351 for residual deficits after the acute phase.
Impact
Failure to document dominance can lead to coding errors.
Mitigation Strategy
Implement mandatory fields in EHR for dominance documentation.
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 Hemiplegia, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Right Hemiplegia
Use these documentation templates to ensure complete and accurate documentation for Right Hemiplegia. These templates include all required elements for proper coding and billing.
Post-Stroke Follow-Up
Specialty: NeurologyRequired Elements
- Patient history of stroke
- Current neurological status
- Imaging results
- Functional assessment
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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