I69.359

HCC Category Mapping

What This Code Means

Weakness or paralysis on one side of the body following a previous stroke, but the specific side is not documented or specified.

Coding Tips

• •Use this code only when the affected side cannot be determined from medical record documentation
• •Query the provider if laterality information is available but not clearly documented

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)
• ✓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