ICD-10 Coding for Right-Sided Hemiparesis(I69.351)
Complete ICD-10-CM coding and documentation guide for Right-Sided Hemiparesis. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Right-Sided Hemiparesis
I69.3Primary Range
Sequelae of cerebrovascular disease
This range includes codes for conditions resulting from previous cerebrovascular events, such as strokes, affecting the right side.
Key Information: ICD-10 code for right-sided hemiparesis
Essential facts and insights about Right-Sided Hemiparesis
Primary ICD-10-CM Code for right sided hemiparesis
Decision Criteria
clinical Criteria
- Right-sided weakness with imaging evidence of left hemisphere infarction
documentation Criteria
- Explicit mention of 'right dominant side' or default to dominant if unspecified
Applicable To
- Right-sided hemiparesis due to past stroke
Excludes
- Acute stroke (I63.x)
Clinical Validation Requirements
- Neurological exam showing right-sided weakness
- Imaging (CT/MRI) confirming left hemisphere infarction
Code-Specific Risks
- Misclassification if dominance is not documented
- Using acute stroke codes instead of sequela codes
Coding Notes
- Ensure documentation specifies 'right dominant side' or default to dominant if not specified.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Essential (primary) hypertension
I10Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Other symptoms and signs involving the nervous and musculoskeletal systems
R29.818Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Right-Sided 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: Misinterpretation of patient's functional status., Regulatory: Potential coding errors leading to audits., Financial: Incorrect reimbursement due to misclassification.
Mitigation Strategy
Always document patient's handedness., Clarify dominance in neurological assessments.
Impact
Reimbursement: Incorrect DRG assignment leading to potential underpayment., Compliance: Non-compliance with coding guidelines for chronic conditions., Data Quality: Inaccurate representation of patient history and condition.
Mitigation Strategy
Use I69.351 for sequelae of stroke, not I63.x for acute events.
Impact
Lack of documentation on whether the right side is dominant can lead to coding errors.
Mitigation Strategy
Standardize documentation practices to include 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-Sided Hemiparesis, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Right-Sided Hemiparesis
Use these documentation templates to ensure complete and accurate documentation for Right-Sided Hemiparesis. These templates include all required elements for proper coding and billing.
Follow-up visit for post-stroke hemiparesis
Specialty: NeurologyRequired Elements
- Patient history of stroke
- Current neurological status
- Functional impact on daily activities
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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