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I69.954
ICD-10-CM
Left-Sided Weakness Due to CVA

Find information on left-sided weakness due to cerebrovascular accident (CVA). This resource covers clinical documentation, medical coding, and healthcare guidance related to left hemiparesis, left-sided hemiplegia, and stroke. Learn about ICD-10 codes for CVA with left-sided weakness, neurological assessment, and post-stroke rehabilitation. Explore resources for healthcare professionals, including documentation tips and coding best practices for accurate representation of left-sided weakness resulting from a stroke.

Also known as

Left Hemiparesis Post-Stroke
Left-Sided Paresis Following CVA

Diagnosis Snapshot

Key Facts
  • Definition : Loss of strength on the left side of the body due to a stroke (cerebrovascular accident).
  • Clinical Signs : Left-sided hemiparesis or hemiplegia, facial droop, speech difficulty, sensory loss.
  • Common Settings : Emergency room, stroke unit, inpatient rehabilitation facility, home healthcare.

Related ICD-10 Code Ranges

Complete code families applicable to AAPC I69.954 Coding
I60-I69

Cerebrovascular diseases

Covers various cerebrovascular conditions like stroke.

I69

Sequelae of cerebrovascular disease

Addresses long-term effects after a cerebrovascular event.

G81

Hemiplegia and hemiparesis

Describes one-sided weakness or paralysis.

R29

Other symptoms and signs involving the nervous and musculoskeletal systems

Includes other neurological symptoms if more specific codes don't apply.

Code-Specific Guidance

Decision Tree for

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

Is the CVA acute (within 24 hours)?

  • Yes

    Is there occlusion of cerebral artery?

  • No

    Is the CVA due to infarction?

Code Comparison

Related Codes Comparison

When to use each related code

Description
Left-sided weakness after stroke
Left hemiparesis after CVA
Left hemiplegia due to stroke

Documentation Best Practices

Documentation Checklist
  • Document left-sided weakness specifics (e.g., arm, leg, face)
  • CVA etiology (ischemic vs. hemorrhagic) MUST be documented
  • NIH Stroke Scale (NIHSS) score required for CVA severity
  • Document impact on ADLs (activities of daily living)
  • Onset date and time of left-sided weakness crucial

Coding and Audit Risks

Common Risks
  • Laterality Specificity

    Coding left-sided weakness requires specific documentation of the affected side to avoid unspecified codes impacting reimbursement and quality metrics. CDI can clarify this.

  • CVA Acuity Mismatch

    Incorrect coding of CVA acuity (e.g., acute, subacute, chronic) can lead to inaccurate DRG assignment and claims denials. CDI should query physicians for clarity.

  • Dominant vs. Non-Dominant

    Documenting whether the affected side is dominant or non-dominant impacts functional assessment and rehabilitation coding. CDI should query for accurate documentation.

Mitigation Tips

Best Practices
  • Timely neurological exam for accurate CVA diagnosis (ICD-10 I63.9)
  • Detailed documentation of weakness laterality for proper coding (CPT 95853)
  • Assess functional impact for optimal care plan and compliance (CMS guidelines)
  • NIHSS use for standardized stroke severity assessment and CDI
  • Regular reassessment of left-sided weakness for progress tracking and coding updates

Clinical Decision Support

Checklist
  • Confirm sudden onset left-sided weakness (ICD-10 I63.9)
  • Rule out non-stroke mimics (hypoglycemia, seizure)
  • Document NIHSS assessment for stroke severity
  • Verify imaging (CT/MRI) for ischemic/hemorrhagic CVA

Reimbursement and Quality Metrics

Impact Summary
  • **Reimbursement and Quality Metrics Impact Summary: Left-Sided Weakness Due to CVA**
  • **Keywords:** CVA reimbursement, ICD-10 I69.35, medical coding accuracy, stroke quality reporting, hemiparesis billing, hospital metrics
  • **Impacts:**
  • - Reduced reimbursement if I69.35 not coded with laterality and acuity specifiers.
  • - Impacts stroke care quality measures (e.g., tPA administration time).
  • - Affects hospital readmission rates and value-based purchasing programs.
  • - Influences severity-adjusted stroke outcome reporting.

Streamline Your Medical Coding

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

Quick Tips

Practical Coding Tips
  • Code I69.358 for CVA
  • Document weakness laterality
  • Specify if acute/chronic CVA

Documentation Templates

Patient presents with left-sided weakness consistent with a cerebrovascular accident (CVA), also known as a stroke.  Onset of symptoms occurred on [Date of Onset] at approximately [Time of Onset].  The patient exhibits hemiparesis affecting the left side of the body, including decreased motor strength in the left arm and leg.  Neurological assessment reveals [Specific neurological deficits, e.g., left facial droop, dysarthria, sensory loss on the left side].  The patient's medical history includes [Relevant medical history, e.g., hypertension, hyperlipidemia, atrial fibrillation, diabetes, prior stroke].  Current medications include [List current medications].  Differential diagnosis includes transient ischemic attack (TIA), Todd's paralysis, and other neurological conditions.  Brain imaging (CT scan without contrast obtained on [Date of Imaging]) [Findings of imaging, e.g., revealed a hypodense area in the right [Location of lesion, e.g., parietal lobe], suggestive of an ischemic stroke. No evidence of hemorrhage.].  National Institutes of Health Stroke Scale (NIHSS) score at time of presentation was [NIHSS score].  The patient's current blood pressure is [Blood Pressure reading], heart rate is [Heart Rate], and respiratory rate is [Respiratory Rate].  Treatment plan includes [Treatment plan, e.g., thrombolytic therapy with alteplase administered per protocol,  neurology consult obtained, close monitoring for neurological changes, initiation of aspirin therapy,  physical therapy and occupational therapy consultations].  Patient is admitted for further evaluation and management of left-sided weakness due to CVA.  ICD-10 code I69.359 (Other specified hemiplegia and hemiparesis affecting left dominant side) is assigned.  Continued monitoring for complications such as cerebral edema, recurrent stroke, and dysphagia is warranted. Prognosis for recovery is dependent on extent of the infarct and ongoing neurological assessments.
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