2025 ICD-10-CM code I69.954
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Diseases of the circulatory system - Cerebrovascular diseases (I60-I69) Diseases of the circulatory system (I00-I99) Feed
Hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting the left non-dominant side.
Medical necessity for coding I69.954 is established by documentation supporting the presence of hemiplegia or hemiparesis following a cerebrovascular event. The documentation should clearly demonstrate the functional impact of the neurological deficits on the patient's daily life, necessitating rehabilitation and/or ongoing medical management.
The clinical responsibility for this code involves assessing the patient's neurological status, including muscle strength, range of motion, and functional abilities.This may involve physical therapy, occupational therapy, speech therapy, and other rehabilitative interventions depending on the severity of the hemiplegia or hemiparesis.Ongoing monitoring and management of any associated complications (e.g., contractures, spasticity, pressure sores) are also key clinical responsibilities.
- Diseases of the circulatory system (I00-I99)
- I69.954 is within the broader category of cerebrovascular diseases (I60-I69) and more specifically, under unspecified cerebrovascular disease sequelae.
In simple words: This code describes weakness or paralysis on one side of the body after a stroke or other unspecified brain blood vessel problem, specifically affecting the left side of the brain in individuals where the left side is not their dominant side.
This ICD-10-CM code classifies hemiplegia and hemiparesis (paralysis or weakness affecting one side of the body) as a sequela (a condition that develops as a consequence of a previous disease or injury) of an unspecified cerebrovascular disease affecting the left non-dominant side of the brain.The etiology of the cerebrovascular event is not specified, and the code is used when the resulting hemiplegia or hemiparesis is the primary focus of the encounter.
Example 1: A 70-year-old female patient presents with left-sided weakness and paralysis following an unspecified cerebrovascular accident (CVA).She displays difficulty with ambulation and activities of daily living.I69.954 is used to code the residual hemiplegia affecting her left non-dominant side., A 65-year-old male patient with a history of hypertension and diabetes experiences an unspecified cerebrovascular event. After discharge, he exhibits persistent weakness in his left arm and leg. I69.954 appropriately reflects his post-stroke condition involving the non-dominant side., An 80-year-old female with a history of atrial fibrillation is admitted with acute neurological deficits, including left-sided weakness. The cause of the CVA is not fully determined, but resulting left-sided hemiparesis is significant. I69.954 captures the sequela in this case of unspecified cerebrovascular disease.
Detailed neurological examination documenting the extent of the hemiplegia or hemiparesis (e.g., muscle strength grading, range of motion assessment).Imaging studies (e.g., CT scan, MRI) demonstrating evidence of prior cerebrovascular disease.Physical therapy or occupational therapy notes documenting the patient's functional limitations and progress in rehabilitation.Physician's notes detailing the patient's history, clinical findings, and diagnostic impressions.Records must clearly indicate that the left side affected is the non-dominant side.
** This code is exempt from Present on Admission (POA) reporting.Always cross-reference with other diagnostic codes to ensure a complete and accurate representation of the patient's condition.
- Payment Status: Active
- Specialties:Neurology, Physical Medicine and Rehabilitation, Cardiology
- Place of Service:Inpatient Hospital, Outpatient Hospital, Skilled Nursing Facility, Rehabilitation Facility, Office