I69.841

HCC Category Mapping

What This Code Means

Weakness or paralysis of one leg on the right side of the body (the dominant side) following a stroke or other brain blood vessel disease.

Coding Tips

• •Monoplegia of lower limb affects mobility and ambulation; assess need for assistive devices
• •Confirm right side dominance is documented in the medical record

Clinical Significance

Monoplegia of the lower limb as a sequela of other cerebrovascular disease not classified elsewhere 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 the specific cerebrovascular disease 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
• ✓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