I69.254

HCC Category Mapping

What This Code Means

This code describes weakness or paralysis on the left side of the body that resulted from bleeding in the brain (not caused by trauma). The left side is the non-dominant side, meaning the person is right-handed.

Coding Tips

• •Verify the laterality (left vs. right) and dominance (dominant vs. non-dominant) are clearly documented in the medical record before assigning this code
• •This is a sequela code (I69 category) and should only be used when the hemorrhage has already occurred and the hemiplegia/hemiparesis is a residual effect, not the acute phase

Clinical Significance

Hemiplegia and hemiparesis 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. Hemiplegia involves paralysis or significant weakness affecting one entire side of the body, requiring ongoing rehabilitation, fall prevention strategies, and often assistive devices for activities of daily living. This condition is a key risk adjustment indicator as it reflects severe neurological damage with high resource utilization for therapy, home health, and durable medical equipment.

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
• ✓Description of hemiplegia or hemiparesis affecting one entire side of the body (both upper and lower extremities)
• ✓Current functional status and severity of the hemiplegia/hemiparesis (complete vs incomplete paralysis)
• ✓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