2025 ICD-10-CM code I69.859
(Active) Effective Date: N/A Revision Date: N/A Cerebrovascular diseases - Sequelae of cerebrovascular disease Chapter 9: Diseases of the circulatory system Feed
Hemiplegia and hemiparesis following other cerebrovascular disease affecting unspecified side.
Medical necessity is established by confirming the presence of hemiplegia or hemiparesis as a direct result of a previous cerebrovascular event. The clinical documentation must support a causal relationship between the CVD and the reported sequelae.
The clinical responsibility would involve diagnosing the underlying cerebrovascular disease and assessing the resulting hemiplegia or hemiparesis.Treatment might include physical therapy, occupational therapy, medication to manage symptoms, and potentially other interventions depending on the severity and specific needs of the patient.
In simple words: This code is for when someone has weakness or paralysis on one side of their body because of a previous stroke or other circulatory system problem, but it's not known which side is affected.
This code classifies hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one side of the body) as sequelae (lasting effects) of cerebrovascular disease (CVD) affecting an unspecified side.It is used when the specific side affected is unknown or not documented.The underlying CVD must have already occurred and resulted in the persistent hemiplegia or hemiparesis.
Example 1: A 70-year-old patient presents with persistent right-sided weakness following a stroke six months prior. The side of the weakness is documented but a more specific code is not available. I69.859 would be reported, noting that the unspecified side means right sided weakness., A patient is seen in a rehabilitation facility following a cerebrovascular event, but documentation lacks clarity on the affected side.Since the exact location of the paralysis or weakness is unknown, I69.859 is the appropriate code., An elderly patient is admitted to the hospital with significant neurological deficits following a suspected stroke. However, due to the patient's altered mental status and inability to communicate effectively, determining the precise side of the neurological involvement is challenging. The attending physician documents significant residual neurological deficits, and I69.859 is used.
Thorough documentation should include the history of the cerebrovascular event, the presence of hemiplegia or hemiparesis, and any attempts to specify the affected side.Imaging studies (CT scan, MRI) confirming the cerebrovascular event are crucial, and a neurological examination detailing the extent of the neurological deficit should also be documented.
** This code is for sequelae, meaning the lasting effects after the initial cerebrovascular event has resolved.It is important to differentiate this from the acute phase of a stroke.If the patient is still in the acute phase of a stroke, a different ICD-10 code is necessary, reflecting the type of stroke and its acute presentation.Consider the use of additional codes to identify contributing factors such as hypertension or diabetes.
- Payment Status: Active
- Specialties:Neurology, Physical Medicine and Rehabilitation, Cardiology
- Place of Service:Inpatient Hospital, Outpatient Hospital, Skilled Nursing Facility, Rehabilitation Facility, Office