ICD-10-CM Code for Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side I69. 354.
Other sequelae of cerebral infarction I69. 398 is a billable/specific ICD-10-CM code that can be used to indicate a diagnosis for reimbursement purposes. The 2022 edition of ICD-10-CM I69. 398 became effective on October 1, 2021.
I69. 354 - Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side | ICD-10-CM.
“Weakness” is code 728.87 ICD-9, M62. 81 ICD-10, which is NOT A HCC. “Weakness” is a symptom, whereas “paresis” including monoparesis, hemiparesis and even quadriparesis are diagnoses.
If a physician clearly documents that a patient is being seen who has a history of cerebrovascular disease or accident with residual effects, a code from category I69* should be assigned.
Residual neurological effects of a stroke or cerebrovascular accident (CVA) should be documented using CPT category I69 codes indicating sequelae of cerebrovascular disease. Codes I60-67 specify hemiplegia, hemiparesis, and monoplegia and identify whether the dominant or nondominant side is affected.
Injury to the left side of the brain, which controls language and speaking, can result in right-sided weakness. Left-sided weakness results from injury to the right side of the brain, which controls nonverbal communication and certain behaviors.
I63. 9 - Cerebral infarction, unspecified | ICD-10-CM.
History of Stroke (ICD-10 code Z86. 73) should be used when the patient is being seen in an out patient setting subsequent to an inpatient stay. In addition, this code should be used when the patient does not exhibit neurologic deficits due to cerebrovascular disease (i.e., no late effects due to stroke).
In the encoder I put late/effect/CVA/hemiplegia/ unspecified (because it doesn't say whether left side was dominant or not. The code comes up 438.20 and tabular confirms Hemiplegia/hemipararesis (Late effect of CVA).
Go with 438.89. Look at the tip under 438.89 in the ICD-9 expert. Use 728.87 as your secondary code for residual weakness due to CVA.