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2025 ICD-10-CM code I69.342

Monoplegia of the lower limb following a cerebral infarction affecting the left dominant side.

Follow official ICD-10-CM coding guidelines provided by the Centers for Medicare & Medicaid Services (CMS). Pay close attention to the inclusion and exclusion notes for this code and related codes in the I69 category to ensure accurate assignment.

No modifiers apply to ICD-10 codes.

Medical necessity for this code is established through the documentation of a cerebral infarction causing monoplegia in the lower limb. The documentation must support the diagnosis with clinical findings and neuroimaging results that establish the location and extent of the infarction affecting the dominant hemisphere, leading to the resulting neurological deficit.This should align with standards of care.

The clinical responsibility for coding I69.342 rests with the physician or qualified healthcare professional who diagnoses and manages the patient's condition.This includes assessment of the stroke's impact, neurological examination to determine the extent of the monoplegia, and development of a rehabilitation plan.

IMPORTANT:Related codes include I69.341 (right dominant side), I69.343 (right non-dominant side), I69.344 (left non-dominant side), and I69.349 (unspecified side).Consider also codes from other chapters if there are additional comorbidities present such as hypertension, diabetes, or other neurological conditions.

In simple words: This code describes paralysis in one leg after a stroke that affected the left side of the brain. This is the side that usually controls language and other important brain functions for right-handed people.

This code signifies monoplegia (paralysis of one limb) in the lower limb as a sequela (a condition that develops as a consequence of a previous disease or injury) of a cerebral infarction (stroke) affecting the left dominant hemisphere of the brain.It is specifically used when the paralysis is confined to a single lower limb and the left side of the brain, which is typically the dominant hemisphere in most right-handed individuals, is affected by the infarction.

Example 1: A 65-year-old right-handed male presents with sudden onset of left leg weakness following a documented stroke.Neurological examination confirms monoplegia of the left lower extremity with preserved function in other limbs.Brain imaging demonstrates an infarction in the right cerebral hemisphere. Code I69.342 is assigned., A 72-year-old female with a history of hypertension experiences a stroke resulting in right leg weakness.Neurological exam reveals monoplegia of the right lower limb, and brain imaging shows an infarction in the left cerebral hemisphere. Code I69.342 is assigned because the left hemisphere is dominant., An 80-year-old patient with a history of atrial fibrillation presents with a sudden onset of left leg weakness and difficulty with ambulation.Neurological examination reveals monoplegia in the left lower extremity.MRI of the brain shows an infarction in the right cerebral hemisphere. I69.342 is appropriate.

Detailed medical history including risk factors for stroke (hypertension, diabetes, atrial fibrillation, smoking), a complete neurological examination documenting the extent of the monoplegia, and results of neuroimaging studies (CT scan or MRI) demonstrating the cerebral infarction are crucial for proper coding. Discharge summaries and progress notes are also required to accurately reflect the ongoing treatment and recovery process.

** This code is highly specific and requires careful consideration of laterality and dominance.Accurate documentation is essential to avoid miscoding.

** Only Enterprise users with EHR integration can access case-specific answers. Click here to request access.

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