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2025 ICD-10-CM code I69.35

Hemiplegia and hemiparesis following cerebral infarction.

Always use the most specific code possible. The additional sixth digit is mandatory for I69.35 to specify laterality and dominance.Careful clinical documentation is crucial to ensure appropriate code selection.Consult the official ICD-10-CM guidelines for complete coding instructions.

Modifiers are not applicable to ICD-10-CM codes.

Medical necessity is established through thorough documentation demonstrating the presence of persistent hemiplegia or hemiparesis as a direct consequence of a previous cerebral infarction. This necessitates ongoing medical management, physical therapy, or other interventions to address the residual deficits and improve functional capacity.

The clinical responsibility for this code falls upon the physician who manages the patient's post-stroke care, including assessment of residual deficits and ongoing management of symptoms.This might involve neurologists, physiatrists, or other specialists depending on the patient's needs.

IMPORTANT:Additional sixth digits are required to specify laterality (right or left) and dominance (dominant or non-dominant hemisphere).Related codes include I69.34 (other paralytic syndromes), I69.36 (other paralytic syndromes following cerebral infarction), and I69.39 (other sequelae of cerebral infarction).If only a history of CVA with no residual effects is present, a different code should be used.Use of code I69.35 requires documentation supporting current residual weakness.

In simple words: This code describes lasting weakness or paralysis on one side of the body after a stroke.

This code classifies hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one side of the body) as sequelae (residual effects) following a cerebral infarction (stroke).The code requires an additional sixth digit to specify laterality (which side is affected) and dominance (dominant or non-dominant hemisphere).

Example 1: A 65-year-old patient presents with persistent right-sided weakness and paralysis three months after an ischemic stroke.The physician documents residual right hemiplegia affecting the dominant hemisphere.Code I69.351 is used., A 72-year-old patient reports left-sided weakness and difficulty with fine motor skills following a previous stroke.Neurological examination confirms left hemiparesis affecting the non-dominant hemisphere.Code I69.354 is applied., A patient is seen in physical therapy several months after a stroke.They show persistent weakness on their left side, impacting daily activities. The physician notes the left hemiparesis is impacting the non-dominant hemisphere.Code I69.354 would be assigned.

Detailed documentation of the patient's history of cerebral infarction (including date, type of stroke), neurological examination findings (including laterality and dominance of affected hemisphere), and the presence of persistent hemiplegia or hemiparesis.The documentation should clearly indicate that the weakness or paralysis is a residual effect of the stroke and is still present at the time of the encounter.

** This code should only be used when hemiplegia or hemiparesis are documented as a direct residual effect of a cerebral infarction.If the patient has a history of stroke but no current residual deficits, a different code should be used.Proper documentation is critical for accurate coding and reimbursement.

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