I69.339

HCC Category Mapping

What This Code Means

Weakness or paralysis affecting one arm after a stroke when the side of the body affected or the patient's hand dominance is not specified.

Coding Tips

• •Use this code only when dominance or affected side cannot be determined from documentation
• •Query the provider if possible to obtain more specific information for better code selection

Clinical Significance

Monoplegia of the upper limb as a sequela of a cerebral infarction (ischemic stroke) 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 cerebral infarction (stroke) 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
• ✓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