I69.042

HCC Category Mapping

What This Code Means

Weakness or paralysis of one leg on the left side of the body that is the person's dominant side, occurring as a long-term effect of bleeding in the brain (subarachnoid hemorrhage).

Coding Tips

• •This code requires documentation of the dominant side affected; verify patient handedness or dominant leg use in medical record
• •Assign only when monoplegia is a sequela of a previous nontraumatic subarachnoid hemorrhage, not acute phase

Clinical Significance

This code captures monoplegia of the lower limb (left dominant side) as a late effect (sequela) of a prior nontraumatic subarachnoid hemorrhage. Monoplegia affecting a single limb following subarachnoid hemorrhage reflects residual neurological damage from the original hemorrhagic stroke. Accurate capture of stroke sequelae is essential for risk adjustment, as these chronic deficits indicate ongoing care needs including rehabilitation, assistive devices, and increased fall risk.

Documentation Requirements

• ✓Clear documentation of monoplegia as a current, active condition (not just historical)
• ✓Documentation linking the paralytic deficit to a prior nontraumatic subarachnoid hemorrhage
• ✓Specification of affected side and dominance (right dominant, left dominant, right non-dominant, left non-dominant)
• ✓Current functional status assessment and impact on activities of daily living
• ✓Ongoing treatment plan (physical therapy, occupational therapy, medications for spasticity)
• ✓Documentation that the original stroke was a subarachnoid hemorrhage specifically (not intracerebral hemorrhage or cerebral infarction)

Commonly Confused Codes