2025 ICD-10-CM code I69.354
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Cerebrovascular diseases - Sequelae of cerebrovascular disease Diseases of the circulatory system (I00-I99) Feed
Hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side.
No modifiers are applicable to ICD-10-CM codes.
Medical necessity is established by the presence of persistent hemiplegia or hemiparesis following a confirmed cerebral infarction.The ongoing effects significantly impact the patient's functional abilities and require medical management, rehabilitation, or supportive care.
The clinical responsibility rests with the physician or other qualified healthcare professional managing the patient's post-stroke care, including assessment of neurological deficits, rehabilitation planning, and ongoing monitoring for complications.
- Diseases of the circulatory system (I00-I99)
- I69.35 Hemiplegia and hemiparesis following cerebral infarction
In simple words: This code describes lasting weakness or paralysis on one side of the body, specifically the left side, after a stroke.It's used when the stroke happened in the past and the weakness or paralysis remains.
This code signifies hemiplegia (paralysis affecting one side of the body) and hemiparesis (weakness affecting one side of the body) as sequelae (residual effects) of a cerebral infarction (stroke) specifically affecting the left non-dominant side of the body.The diagnosis requires prior occurrence of a cerebral infarction and the persistent presence of hemiplegia or hemiparesis.Laterality (dominant versus non-dominant) must be specified; if the patient is left-sided affected, the side is considered non-dominant unless otherwise specified. This code is utilized for individuals experiencing ongoing effects of a previous stroke.
Example 1: A 68-year-old right-handed female presents with persistent left-sided weakness (hemiparesis) six months post-cerebral infarction.Neurological exam confirms residual left hemiparesis. I69.354 is coded along with codes describing the initial stroke (I63.x - cerebral infarction due to specific cause) and any other co-morbidities., A 75-year-old left-handed male patient, three years post-left cerebral hemisphere stroke, exhibits ongoing left-sided paralysis (hemiplegia).Physical therapy notes document ongoing need for assistance with activities of daily living (ADLs). I69.354 is coded., A 55-year-old patient with a history of cerebral infarction presents with left-sided weakness and difficulty with speech (aphasia).Due to persistent left sided deficits, I69.354 is used along with codes reflecting the aphasia.
Complete documentation should include the date and nature of the initial cerebral infarction, neurological examination findings confirming the presence and laterality of hemiplegia or hemiparesis, and any associated symptoms or functional limitations.Detailed records of any rehabilitation interventions should also be included.
** Accurate coding requires clear documentation linking the hemiplegia/hemiparesis to a prior cerebral infarction. The documentation should explicitly state whether the affected side is dominant or non-dominant. For ambidextrous individuals, the default should be dominant if the right side is affected and non-dominant if the left side is affected.Miscoding can lead to inaccurate reimbursement and potentially impact the patient's care plan.
- Revenue Code: Revenue codes will vary depending on the services rendered and the healthcare facility.Consult your facility's revenue code guidelines.
- RVU: RVUs are not directly associated with ICD-10 codes.RVUs are specific to CPT codes used for procedural billing. The reimbursement for this code is dependent on the services provided and the payer's fee schedule.
- Global Days: Not applicable to ICD-10 codes.
- Payment Status: Active
- Modifier TC rule: Not applicable to ICD-10-CM codes.
- Fee Schedule: Not applicable to ICD-10-CM codes.Reimbursement is determined by the payer's fee schedule and the services provided.
- Specialties:Neurology, physiatry (rehabilitation medicine), and internal medicine
- Place of Service:Inpatient Hospital, Outpatient Hospital, Office, Skilled Nursing Facility,Other Place of Service (depending on the care setting)