ICD-10 Coding for Left Hemiparesis due to CVA(I69.354)
Complete ICD-10-CM coding and documentation guide for Left Hemiparesis due to CVA. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Left Hemiparesis due to CVA
I69.30-I69.39Primary Range
Sequelae of cerebrovascular disease
This range includes codes for conditions resulting from previous cerebrovascular accidents, such as hemiparesis.
Hemiplegia, unspecified
Used when hemiparesis is documented without a specified cause or laterality.
Key Information: ICD-10 code for left hemiparesis due to CVA
Essential facts and insights about Left Hemiparesis due to CVA
Primary ICD-10-CM Code for left hemiparesis due to cva
Decision Criteria
clinical Criteria
- Presence of left-sided weakness linked to a past CVA
documentation Criteria
- Explicit documentation of non-dominance or right-handedness
Applicable To
- Left-sided weakness due to past CVA
Clinical Validation Requirements
- Documented history of CVA
- Current physical exam showing left-sided weakness
- Linkage of hemiparesis to past CVA
Code-Specific Risks
- Incorrectly coding as acute CVA
- Lack of documentation linking hemiparesis to CVA
Coding Notes
- Ensure documentation specifies the causal relationship between the CVA and hemiparesis.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits
Z86.73Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Hemiplegia, unspecified affecting left side
G81.94Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Left Hemiparesis due to CVA to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code I69.354.
Impact
Clinical: Misrepresentation of patient's current condition., Regulatory: Potential audit trigger., Financial: Incorrect billing leading to denied claims.
Mitigation Strategy
Ensure current deficits are documented, Link deficits to past CVA
Impact
Reimbursement: Incorrect DRG assignment leading to potential underpayment., Compliance: Risk of audit and compliance issues., Data Quality: Inaccurate patient records affecting clinical decision-making.
Mitigation Strategy
Use I69 codes for residual effects post-acute phase.
Impact
Failure to document linkage between hemiparesis and past CVA.
Mitigation Strategy
Educate providers on documentation requirements.
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 Left Hemiparesis due to CVA, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Left Hemiparesis due to CVA
Use these documentation templates to ensure complete and accurate documentation for Left Hemiparesis due to CVA. These templates include all required elements for proper coding and billing.
Follow-up visit for left hemiparesis post-CVA
Specialty: NeurologyRequired Elements
- Patient history of CVA
- Current neurological exam
- Linkage of hemiparesis to CVA
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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