I69.965

HCC Category Mapping

What This Code Means

Weakness or paralysis affecting both sides of the body in a symmetrical or asymmetrical pattern following a stroke.

Coding Tips

• •Bilateral designation indicates involvement of both right and left sides; document whether the weakness is symmetrical or asymmetrical
• •This code is used for complex paralytic syndromes affecting multiple limbs on both sides of the body

Clinical Significance

Other paralytic syndromes following unspecified cerebrovascular disease capture residual motor deficits that do not fit the classic patterns of hemiplegia or monoplegia, such as locked-in syndrome, quadriplegia, or atypical paralytic presentations following cerebrovascular events. These conditions often require complex, multidisciplinary care including neurological monitoring, physical and occupational therapy, and specialized nursing services. Proper coding ensures these high-acuity, high-resource patients are appropriately reflected in risk adjustment calculations.

Documentation Requirements

• ✓Documentation of the specific type of prior cerebrovascular event (stroke, hemorrhage, or other cerebrovascular disease) that caused the sequela
• ✓Clear statement establishing a causal relationship between the prior cerebrovascular event and the current neurological deficit
• ✓Documentation that the condition is a late effect or sequela, not an acute or evolving stroke
• ✓Description of the specific paralytic pattern (e.g., quadriplegia, locked-in syndrome, or other specified pattern) that distinguishes this from hemiplegia or monoplegia
• ✓Documentation confirming bilateral involvement of the paralytic syndrome
• ✓Current functional status assessment including impact on activities of daily living, mobility, and need for assistive devices or caregiver support
• ✓Ongoing treatment plan addressing the neurological deficit (physical therapy, occupational therapy, medications, or other interventions)

Commonly Confused Codes