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
Sequelae of cerebrovascular disease
Covers the long-term effects of a stroke, including hemiparesis.
Cerebrovascular diseases
Includes various types of stroke and related conditions.
Cerebral infarction
Specifically relates to strokes caused by blockage of blood flow.
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?
When to use each related code
Description |
---|
Left Hemiparesis after stroke |
Right Hemiplegia after stroke |
Left-sided weakness (transient) |
Coding hemiparesis without specifying left or right can lead to inaccurate reimbursement and data analysis. Proper documentation is crucial.
Missing documentation of acute vs. chronic CVA impacts code selection (I69.359 vs. I69.351). CDI can clarify CVA timing.
Failing to document dominant vs. non-dominant side involvement affects coding for functional limitations and rehabilitation planning.
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.