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
Cerebrovascular diseases
Covers various cerebrovascular conditions like stroke.
Sequelae of cerebrovascular disease
Addresses long-term effects after a cerebrovascular event.
Hemiplegia and hemiparesis
Describes one-sided weakness or paralysis.
Other symptoms and signs involving the nervous and musculoskeletal systems
Includes other neurological symptoms if more specific codes don't apply.
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?
When to use each related code
Description |
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Left-sided weakness after stroke |
Left hemiparesis after CVA |
Left hemiplegia due to stroke |
Coding left-sided weakness requires specific documentation of the affected side to avoid unspecified codes impacting reimbursement and quality metrics. CDI can clarify this.
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.
Documenting whether the affected side is dominant or non-dominant impacts functional assessment and rehabilitation coding. CDI should query for accurate documentation.
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.