I69.232

HCC Category Mapping

What This Code Means

Weakness or paralysis of one arm on the left side (the person's dominant side) resulting from a brain bleed.

Coding Tips

• •The fifth character '2' indicates left dominant side; this is less common but must be documented when the patient is left-dominant
• •Verify dominance documentation in the medical record to ensure accurate code selection

Clinical Significance

Monoplegia of the upper limb as a sequela of a nontraumatic intracranial hemorrhage other than intracerebral (such as subarachnoid or subdural hemorrhage) represents a chronic neurological deficit that significantly impacts the patient's functional status and ongoing care needs. Upper limb monoplegia affects the patient's ability to perform fine motor tasks, self-care activities, and may require occupational therapy and adaptive equipment. Accurate capture of this sequela is important for risk adjustment as it reflects ongoing neurological impairment requiring continued medical management and rehabilitation services.

Documentation Requirements

• ✓Documentation of prior other nontraumatic intracranial hemorrhage as the causative event with clear causal linkage to the current deficit
• ✓Confirmation that this is a sequela (late effect), not an acute or current cerebrovascular event
• ✓Documentation that paralysis or weakness is isolated to one upper extremity (arm)
• ✓Current functional status of the affected upper limb including strength assessment
• ✓Documentation of which side is affected (right or left)
• ✓Documentation of patient's hand dominance to determine dominant vs non-dominant classification
• ✓Current treatment plan including rehabilitation services, medications, and adaptive equipment
• ✓Assessment that the condition is being actively monitored or managed during the encounter

Commonly Confused Codes