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2025 ICD-10-CM code I69.953

Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting the right non-dominant side.

Follow all applicable ICD-10-CM coding guidelines, including those related to sequencing of codes when multiple diagnoses are present.Ensure proper documentation supports the code selection.

Medical necessity for coding I69.953 is established by documentation supporting the presence of hemiplegia or hemiparesis following a cerebrovascular event.The documentation must clearly link the residual deficits to the prior cerebrovascular disease.Further documentation may be needed to specify the nature of the cerebrovascular event.

The clinical responsibility for this code involves diagnosing and managing the sequelae of cerebrovascular disease, which may include neurological examination, physical therapy, occupational therapy, speech therapy, and medication management. The physician's role is to assess the patient's functional limitations, develop a treatment plan, monitor progress, and provide necessary referrals to other specialists.

IMPORTANT:Related codes include I69.951 (right dominant side), I69.952 (left dominant side), I69.954 (left non-dominant side), and I69.959 (unspecified side).Consider using additional codes to specify the underlying cerebrovascular disease and any associated comorbidities (e.g., hypertension, diabetes).

In simple words: This code describes weakness or paralysis on one side of the body that happened after a problem with blood flow in the brain on the right, non-dominant side.More information is needed to determine the exact cause of the blood flow problem.

This ICD-10-CM code classifies hemiplegia (paralysis of one side of the body) and hemiparesis (weakness of one side of the body) as sequelae (late effects) of an unspecified cerebrovascular disease affecting the right non-dominant side of the brain.The unspecified nature of the cerebrovascular disease necessitates further investigation and documentation to specify the underlying cause (e.g., stroke, transient ischemic attack).

Example 1: A 65-year-old patient presents with right-sided weakness and paralysis following a stroke (the type of stroke is unspecified).I69.953 is used to code the residual hemiplegia/hemiparesis., A 72-year-old patient experiences a cerebrovascular event resulting in right-sided weakness.Further investigation fails to definitively determine the exact type of cerebrovascular disease. I69.953 is appropriate., An 80-year-old patient has persistent right-sided weakness following a previous cerebrovascular accident, with the specific type of CVA being unknown in the patient's medical record. I69.953 is the most accurate coding choice.

Comprehensive documentation should include details of the cerebrovascular event (if known), neurological examination findings (strength, reflexes, sensation), imaging reports (CT scan, MRI), and any functional limitations (mobility, activities of daily living).The physician's assessment of the patient's residual deficits is essential for proper coding.

** When coding hemiplegia or hemiparesis following a cerebrovascular event, use additional codes to specify the laterality (right or left) and dominance (dominant or non-dominant side) of the brain affected.If the underlying cerebrovascular disease is known, code that as well. Always cross-reference with other relevant codes to ensure complete and accurate billing.

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