I69.249

HCC Category Mapping

What This Code Means

Weakness or paralysis of one leg resulting from bleeding in the brain, but the specific side of the body affected is not documented or specified.

Coding Tips

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

Clinical Significance

Monoplegia of the lower 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. Lower limb monoplegia significantly impacts mobility, increases fall risk, and typically requires physical therapy, assistive devices, and ongoing monitoring. This diagnosis is important for risk adjustment as it indicates persistent functional impairment requiring sustained rehabilitative and medical resources.

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 lower extremity (leg)
• ✓Current functional status of the affected lower limb including strength and mobility assessment
• ✓Affected side should be specified when possible; query the provider if laterality is not documented
• ✓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