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I69.954
ICD-10-CM
Left Hemiparesis due to CVA

Find information on left hemiparesis after CVA including clinical documentation tips, ICD-10 codes (I69.351, I69.352, I69.353, I69.359), medical coding guidelines, and healthcare resources for managing cerebrovascular accident and its associated hemiparesis. Learn about accurate diagnosis coding for left-sided weakness, post-stroke rehabilitation, and long-term care for improved patient outcomes. Explore resources for healthcare professionals on documenting neurological deficits, functional limitations, and treatment plans related to left hemiparesis due to CVA.

Also known as

Left-sided weakness post-stroke
Left hemiplegia following stroke

Diagnosis Snapshot

Key Facts
  • Definition : Weakness on the left side of the body caused by a stroke.
  • Clinical Signs : Left-sided muscle weakness, reduced coordination, sensory loss, speech difficulty.
  • Common Settings : Inpatient rehabilitation, stroke unit, skilled nursing facility, outpatient therapy.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC I69.954 Coding
I69

Sequelae of cerebrovascular disease

Covers the long-term effects of a stroke, including hemiparesis.

I60-I69

Cerebrovascular diseases

Includes various types of stroke and related conditions.

I63

Cerebral infarction

Specifically relates to strokes caused by blockage of blood flow.

Code-Specific Guidance

Decision Tree for

Follow this step-by-step guide to choose the correct ICD-10 code.

Is the CVA acute (within 28 days)?

  • Yes

    Current episode or sequela?

  • No

    Is the CVA chronic?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Left Hemiparesis after stroke
Right Hemiplegia after stroke
Left-sided weakness (transient)

Documentation Best Practices

Documentation Checklist
  • Document CVA etiology (ischemic/hemorrhagic)
  • Specify hemiparesis laterality (left)
  • Detail neurological exam findings
  • Assess functional impact of hemiparesis
  • Record stroke scale (NIHSS or similar)

Coding and Audit Risks

Common Risks
  • Laterality Specificity

    Coding hemiparesis without specifying left or right can lead to inaccurate reimbursement and data analysis. Proper documentation is crucial.

  • CVA Timing Documentation

    Missing documentation of acute vs. chronic CVA impacts code selection (I69.359 vs. I69.351). CDI can clarify CVA timing.

  • Dominant Side Impact

    Failing to document dominant vs. non-dominant side involvement affects coding for functional limitations and rehabilitation planning.

Mitigation Tips

Best Practices
  • Document CVA etiology, laterality, and specific deficits for accurate ICD-10 coding (I61.x, I69.xxx).
  • Timely PT/OT consults improve functional outcomes and support I69.xxx coding specificity.
  • Assess cognitive impact as it influences rehab and justifies G81.9 ICD-10 coding if present.
  • Standardized assessment scales (NIHSS) enhance documentation, support coding accuracy, and improve patient care.
  • Regular neuro checks, medication reconciliation, and fall prevention optimize patient safety and comply with CMS guidelines.

Clinical Decision Support

Checklist
  • Sudden onset weakness left side? Document symptom onset time.
  • Assess NIHSS: rule out mimics, document score.
  • Imaging (CT/MRI brain) confirms ischemic/hemorrhagic CVA?
  • Review PMH for stroke risk factors (HTN, AFib, etc.).
  • Screen for dysphagia prior to PO intake.

Reimbursement and Quality Metrics

Impact Summary
  • Left Hemiparesis (CVA) reimbursement impacts coding accuracy for ICD-10 I69.3 (sequelae) and I69.4 (acute) affecting DRG assignment and hospital case mix index.
  • Accurate CVA coding impacts quality metrics reporting for stroke care including time to tPA, rehabilitation, and discharge planning, influencing hospital value-based purchasing.
  • Left Hemiparesis diagnosis specificity impacts medical billing, impacting revenue cycle and denials related to justifying therapy or DME medical necessity.
  • Coding validation for CVA etiology (ischemic/hemorrhagic) impacts severity level and hospital reimbursement, influencing quality reporting for stroke outcomes.

Streamline Your Medical Coding

Let S10.AI help you select the most accurate ICD-10 codes for . Our AI-powered assistant ensures compliance and reduces coding errors.

Quick Tips

Practical Coding Tips
  • Code I69.358 for CVA specificity
  • Document left-sided weakness
  • Query physician for clarity if needed
  • Consider laterality codes (e.g., R53.1)
  • Review ICD-10-CM guidelines for CVA

Documentation Templates

Patient presents with left hemiparesis following a cerebrovascular accident (CVA).  Onset of symptoms occurred on [Date of Onset], characterized by weakness affecting the left side of the body, including the left arm and left leg.  The patient exhibits decreased motor strength in the left upper extremity (LUE) and left lower extremity (LLE), impacting functional mobility and activities of daily living (ADLs).  Neurological examination reveals [Specific neurological findings, e.g., hyperreflexia, spasticity, sensory deficits in the affected limbs].  The patient's medical history is significant for [Relevant medical history, e.g., hypertension, hyperlipidemia, diabetes, atrial fibrillation, prior stroke].  Imaging studies, including a [Type of imaging, e.g., CT scan, MRI] of the brain, confirmed an ischemic stroke affecting the [Location of stroke, e.g., right middle cerebral artery territory].  Differential diagnoses considered included transient ischemic attack (TIA), Bell's palsy, and Todd's paralysis.  Based on the clinical presentation, imaging findings, and neurological examination, the diagnosis of left hemiparesis secondary to cerebrovascular accident is established.  The patient's current medications include [List of medications].  The plan of care includes physical therapy (PT) for gait training and strengthening exercises, occupational therapy (OT) for upper extremity rehabilitation and adaptive equipment assessment, speech therapy (ST) if indicated, and medication management for secondary stroke prevention, including [Specific medications and dosages].  Patient education focuses on stroke risk factors, medication adherence, and lifestyle modifications, including diet and exercise.  Prognosis for functional recovery will be reassessed during follow-up visits.  ICD-10 code I69.359 (Hemiplegia and hemiparesis following cerebrovascular disease affecting unspecified side) and CPT codes for evaluation and management (E/M) services, physical therapy, occupational therapy, and speech therapy will be documented as appropriate.  The patient and their family were counseled on the importance of adherence to the recommended treatment plan and regular follow-up appointments.