I69.054

HCC Category Mapping

What This Code Means

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

Coding Tips

• •Confirm left side is documented as non-dominant to ensure correct code assignment
• •This code indicates sequela status; the original hemorrhage event should be documented in patient history

Clinical Significance

This code captures hemiplegia/hemiparesis (left non-dominant side) as a late effect of prior nontraumatic subarachnoid hemorrhage. Hemiplegia (complete paralysis) or hemiparesis (partial weakness) of one side of the body is the most common and functionally devastating stroke sequela. This condition significantly impacts risk adjustment as it indicates high ongoing care needs including physical therapy, occupational therapy, assistive devices, and increased risk for falls, pressure injuries, and contractures.

Documentation Requirements

• ✓Clear documentation of hemiplegia/hemiparesis 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