I69.354

HCC Category Mapping

What This Code Means

This code describes weakness or paralysis on the left side of the body that resulted from a previous stroke (cerebral infarction), where the left side is the non-dominant side (opposite the person's dominant hand). The patient has residual effects from the stroke affecting their motor function on that side.

Coding Tips

• •Verify the stroke occurred on the left side and confirm it was a cerebral infarction (not hemorrhage or other type) by reviewing the medical record and imaging reports
• •Ensure documentation specifies this is a sequela (late effect) of a previous stroke, not an acute stroke, as the 'I69' category indicates post-stroke conditions; also confirm the left side is documented as non-dominant

Clinical Significance

Hemiplegia and hemiparesis 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. 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 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
• ✓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