I69.049

HCC Category Mapping

What This Code Means

Weakness or paralysis of one leg following brain bleeding (subarachnoid hemorrhage) when the specific side or dominance is not documented or specified.

Coding Tips

• •Use this code only when documentation does not specify which side (right/left) or dominance status is unclear
• •Query provider if dominance information is available to assign a more specific code

Clinical Significance

This code captures monoplegia of the lower limb (unspecified 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