I69.069

HCC Category Mapping

What This Code Means

Weakness or paralysis that developed after a spontaneous brain bleed in the space around the brain, but the specific side affected is not documented or specified.

Coding Tips

• •Use only when laterality cannot be determined from the medical record
• •Query provider if possible to obtain specific laterality information for more precise coding

Clinical Significance

This code captures other paralytic syndrome (unspecified side) as a late effect of prior nontraumatic subarachnoid hemorrhage. Other paralytic syndromes include quadriplegia, locked-in syndrome, or atypical paralytic patterns that do not fit monoplegia or hemiplegia classifications. These conditions represent significant neurological sequelae requiring ongoing management and substantially impact risk adjustment scoring.

Documentation Requirements

• ✓Clear documentation of other paralytic syndrome 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