I69.131

HCC Category Mapping

What This Code Means

Weakness or paralysis of one arm on the right side of the body that occurred as a result of bleeding in the brain, where the right side is the person's dominant side.

Coding Tips

• •Verify documentation specifies the hemorrhage was nontraumatic (spontaneous) and intracerebral
• •Confirm laterality and dominance are clearly documented to select the correct fifth character

Clinical Significance

This code captures monoplegia of the upper limb (right dominant side) as a late effect (sequela) of a prior nontraumatic intracerebral hemorrhage. Intracerebral hemorrhage often causes more severe and persistent neurological deficits than ischemic stroke due to direct brain tissue destruction. Capturing these sequelae accurately reflects the patient's ongoing functional limitations and care needs for risk adjustment purposes.

Documentation Requirements

• ✓Clear documentation of monoplegia as a current, active condition (not just in the patient's history)
• ✓Documentation explicitly linking the paralytic deficit to a prior nontraumatic intracerebral hemorrhage
• ✓Specification of affected side and dominance (right dominant, left dominant, right non-dominant, left non-dominant)
• ✓Current functional assessment documenting the severity and impact on activities of daily living
• ✓Ongoing treatment plan including rehabilitation services, medications, and assistive devices
• ✓Documentation that the original stroke was an intracerebral hemorrhage (bleeding within the brain tissue) — not subarachnoid hemorrhage or cerebral infarction

Commonly Confused Codes