ICD Code I69.354

ICD code I69.354 is used to classify and document a medical condition where a patient experiences hemiplegia (complete paralysis) or hemiparesis (partial weakness) on the left side of the body as a result of a cerebral infarction, commonly known as a stroke, affecting the non-dominant hemisphere of the brain. This code is crucial for healthcare providers to accurately record the specific aftereffects of a stroke, which can significantly impact treatment plans and billing processes.

1. History of Cerebral Infarction: The patient must have a documented history of a cerebral infarction, which is a type of stroke caused by a blockage in the blood vessels supplying the brain.

2. Presence of Hemiplegia or Hemiparesis: The patient exhibits hemiplegia (complete paralysis) or hemiparesis (partial weakness) on one side of the body. This condition must be a direct result of the cerebral infarction.

3. Affecting the Left Side: The hemiplegia or hemiparesis specifically affects the left side of the patient's body.

4. Non-Dominant Side Involvement: The left side of the body is identified as the non-dominant side for the patient. This is typically determined by the patient's handedness, where the non-dominant side is opposite to the hand they primarily use for tasks.

5. Chronic or Residual Condition: The hemiplegia or hemiparesis is a chronic or residual condition, indicating that it persists as a long-term consequence of the cerebral infarction.

6. Clinical Documentation: The condition must be clearly documented in the patient's medical records, including the specific side affected and the non-dominant nature of that side.

7. Exclusion of Other Causes: Other potential causes of hemiplegia or hemiparesis, such as traumatic brain injury or other neurological disorders, should be ruled out to confirm that the symptoms are indeed a result of the cerebral infarction.

For the ICD code I69.354, which pertains to hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, the relevant CPT codes that may be applicable include:

1. 99201-99215: Evaluation and Management (E/M) codes for office or other outpatient visits, depending on the complexity and time spent with the patient.

2. 97110: Therapeutic exercises to develop strength and endurance, range of motion, and flexibility.

3. 97112: Neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and proprioception.

4. 97116: Gait training therapy, which may be necessary for patients experiencing hemiparesis.

5. 97530: Therapeutic activities, using dynamic activities to improve functional performance.

6. G0283: Electrical stimulation (unattended), to aid in muscle re-education and strengthening.

7. 90901: Biofeedback training by any modality, which can be used to help patients gain better control over muscle function.

8. 96116: Neurobehavioral status exam, which may be used to assess cognitive function following a cerebral infarction.

These CPT codes are examples of procedures and services that might be relevant for managing the condition associated with ICD code I69.354. The selection of specific CPT codes will depend on the individual patient's treatment plan and the healthcare provider's clinical judgment.

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