ICD-10 Coding for Left-Sided Hemiplegia(I69.354)
Complete ICD-10-CM coding and documentation guide for Left-Sided Hemiplegia. Includes clinical validation requirements, documentation requirements, and coding pitfalls.
Also known as:
Related ICD-10 Code Ranges
Complete code families applicable to Left-Sided Hemiplegia
I69.3Primary Range
Sequelae of cerebrovascular disease
This range includes codes for hemiplegia and hemiparesis following cerebrovascular disease, specifically for residual conditions post-stroke.
Hemiplegia and hemiparesis
This range includes codes for hemiplegia and hemiparesis not specifically linked to cerebrovascular disease.
Key Information: ICD-10 code for left-sided hemiplegia
Essential facts and insights about Left-Sided Hemiplegia
Primary ICD-10-CM Code for left sided hemiplegia
Decision Criteria
clinical Criteria
- Presence of left-sided weakness post-stroke
documentation Criteria
- Documentation of non-dominant side
Applicable To
- Left-sided hemiplegia post-stroke
- Left hemiparesis due to cerebral infarction
Clinical Validation Requirements
- Imaging confirming cerebral infarction
- Physical exam showing left-sided weakness
- Documentation of non-dominant side
Code-Specific Risks
- Misclassification if dominance is not documented
- Incorrect use if acute stroke is still active
Coding Notes
- Ensure documentation specifies the side and dominance. Default to non-dominant if not specified.
Ancillary Codes
Additional codes that should be used in conjunction with the main diagnosis codes when applicable.
Cerebral infarction, unspecified
I63.9Differential Codes
Alternative codes to consider when ruling out similar conditions to the primary diagnosis.
Spastic hemiplegia affecting left dominant side
G81.12Documentation & Coding Risks
Avoid these common documentation and coding issues when documenting Left-Sided Hemiplegia to ensure proper reimbursement, maintain compliance, and reduce audit risk. These guidelines are particularly important when using ICD-10 code I69.354.
Impact
Clinical: May lead to incorrect treatment plans., Regulatory: Non-compliance with ICD-10 coding standards., Financial: Potential for denied claims or reduced reimbursement.
Mitigation Strategy
Always ask and document patient's dominant side, Use default rules if dominance is not specified
Impact
Reimbursement: May result in lower reimbursement rates., Compliance: Non-compliance with coding guidelines., Data Quality: Decreases accuracy of patient records.
Mitigation Strategy
Always specify laterality and dominance in documentation.
Impact
Using unspecified codes when laterality and dominance are documented.
Mitigation Strategy
Ensure thorough documentation of laterality and dominance.
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-Sided Hemiplegia, with expert answers to help guide accurate code selection and documentation.
Documentation Templates for Left-Sided Hemiplegia
Use these documentation templates to ensure complete and accurate documentation for Left-Sided Hemiplegia. These templates include all required elements for proper coding and billing.
Post-stroke follow-up with left-sided hemiplegia
Specialty: NeurologyRequired Elements
- History of present illness
- Physical examination findings
- Imaging results
- Assessment and plan
Example Documentation
Examples: Poor vs. Good Documentation
Poor Documentation Example
Good Documentation Example
Explanation
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