I69.154

HCC Category Mapping

What This Code Means

Weakness or paralysis on one side of the body (left side, non-dominant) that occurred as a result of bleeding in the brain.

Coding Tips

• •Document whether the patient is right or left-handed to confirm non-dominant side classification
• •Ensure the intracerebral hemorrhage is documented as the cause of the hemiplegia/hemiparesis

Clinical Significance

This code captures hemiplegia/hemiparesis (left non-dominant side) as a late effect of prior nontraumatic intracerebral hemorrhage. Hemiplegia following intracerebral hemorrhage tends to be more severe than from ischemic stroke, as hemorrhage directly destroys brain tissue. This condition carries significant risk adjustment weight reflecting the extensive ongoing care needs including rehabilitation, fall prevention, and management of complications like spasticity and contractures.

Documentation Requirements

• ✓Clear documentation of hemiplegia/hemiparesis 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