2025 ICD-10-CM code I69.854
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Diseases of the circulatory system - Sequelae of cerebrovascular disease Diseases of the circulatory system Feed
Hemiplegia and hemiparesis following other cerebrovascular disease affecting the left non-dominant side.
Modifiers may be applicable depending on the circumstances of service delivery. Consult the current coding guidelines for specific modifier usage.
Medical necessity for coding I69.854 is established by the presence of persistent hemiplegia or hemiparesis following a documented cerebrovascular event. The residual neurological deficit must significantly impair the patient's ability to perform activities of daily living, necessitating rehabilitation services.
Neurologists, physiatrists, and other specialists involved in the rehabilitation and management of stroke patients are responsible for assessing and managing the patient's hemiplegia and hemiparesis, ordering appropriate therapy (physical, occupational, speech), and monitoring for complications.
- Diseases of the circulatory system
- I69.85 (Hemiplegia and hemiparesis following other cerebrovascular disease) > I69.854 (affecting left non-dominant side)
In simple words: This code describes weakness or paralysis on one side of the body (left side, non-dominant) that happened after a stroke or other brain blood vessel problem.It is used to indicate a lasting effect of the previous circulatory system event.
This ICD-10-CM code classifies hemiplegia and hemiparesis (paralysis or weakness affecting one side of the body) as a sequela (a condition that is a consequence of a previous disease or injury) of other cerebrovascular diseases.Specifically, it applies when the affected side is the left non-dominant side.The code excludes sequelae of traumatic intracranial injury.
Example 1: A 65-year-old patient presents with left-sided weakness and paralysis (left non-dominant side) following a right-hemisphere ischemic stroke three months prior.The patient exhibits significant difficulty with ambulation, activities of daily living, and fine motor skills. The physician documents the residual hemiplegia and hemiparesis., A 72-year-old patient with a history of hypertension and diabetes experienced a hemorrhagic stroke affecting the right hemisphere.Following rehabilitation, persistent left-sided weakness remains, impacting their daily activities. This left-sided weakness affects their non-dominant side., An 80-year-old patient with a history of atrial fibrillation experienced a transient ischemic attack (TIA) leading to temporary left-sided weakness. While the weakness resolved, residual mild hemiparesis persists affecting their left, non-dominant side, three months later, impacting their dexterity and balance.
Detailed medical history of the cerebrovascular event, neurological examination findings documenting the hemiplegia/hemiparesis, imaging studies (CT scan, MRI) confirming the location and extent of the brain injury, and documentation of the patient's functional limitations are required.Progress notes should demonstrate the impact on the patient's activities of daily living.
** This code should only be used when the hemiplegia or hemiparesis is a direct result of a cerebrovascular disease and not due to another cause, such as trauma.
- Payment Status: Active
- Specialties:Neurology, Physical Medicine and Rehabilitation, Stroke Care
- Place of Service:Inpatient Hospital, Outpatient Hospital, Skilled Nursing Facility, Rehabilitation Facility, Office