However, you will turn to a V code when your neurologist reports.
When your neurologist tends to a patient who had a stroke, either now or in the distant past, he may record a number of different conditions, which makes your job tougher. If you remember a few guidelines, you will choose the right ICD-9 codes for every cerebrovascular accident (CVA) case your neurologist tends to.
Get specific with two CVA diagnosis codes
When your neurologist tends to a patient who has had a stroke, or CVA, he may document multiple deficiencies, both new as well as lingering. When the patient presents with speech and language deficits, you have two diagnosis codes to select from.
To aid both differentiate the etiology of speech and language deficits, and to add specificity to those deficits, ICD-9 2010 covers two cerebrovascular disease late effects codes 438.13 (Late effects of cerebrovascular disease, speech and language deficits, dysarthria) and 438.14 (…, fluency disorder [stuttering]).
If you’re not aware of the “combined” ICD-9 late effects codes often you might misreport the ICD-9 code(s) indicating that the patient has the active or ongoing condition; in this case a CVA rather than going for the compliant late effect code.
Here’s an example: Your neurologist tends to a patient who suffered a stroke three years ago and has subsequent hemiplegia on her right (dominant) side. Here, you may go for 434.91 (Cerebral artery occlusion, unspecified, with cerebral infarction) and 342.91 (Hemiplegia, unspecified, affecting dominant side) in error as if the patient is dynamically being treated for a current occlusion and hemiplegia rather than going for the correct combined late effects code, 438.21 (Late effect of cerebrovascular disease; Hemiplegia affecting dominant side), according to Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACSPM, CHCO, owner of MJH Consulting in Denver.
Alter your late effects code thinking for CVA
Coding for CVA patients is done a bit differently than coding late effects from other conditions like spinal cord injury from an accident.
Important: When reporting late effects of a stroke, you only require to use a single ICD-9 code to describe the late effects or manifestations of the CVA, rather than go for two ICD-9 codes – one for the residual effect while one for the condition’s cause or as sometimes referenced as the etiology of the manifestation.
Codes recounting late effects of stroke appear in a different section of the ICD-9 manual (438). These codes, like 438.11 (Late effects of cerebrovascular disease; aphasia) and 438.21 (… hemiplegia affecting dominant side), explain both the manifestation as well as the etiology of the condition.
Let documentation show you the way on active versus late effects
“A late effect is any residual effect that results from the original injury and/or condition and can be coded as such at any time after the onset of the condition,” Claudia Kernaghan, CPC, coder for Nevada Imaging Centers in Las Vegas says.
Here’s an example: A patient may have a vertebral fracture and continue to suffer from pain years after the fracture heals. While some late effects present early, others might become obvious months or years later.
Watch out: Do not confuse late effects with complications. A complication is normally associated with a difficulty or problem that takes place with a specific procedure (996.xx) and not a condition owing to the original disease or injury.
To find out if a condition is a late effect, you should look in your neurologist’s documentation for keywords like:
Due to – like “pain in right hip due to fracture last year” • Following – like “personality changes following a brain injury in 1996” • As a consequence of – such as “hemiplegia as a result of CVA” • Residual effect — like “arthritis that’s a residual effect of previous hip fracture.” Capture ‘No Effects’ with the help of V12.54 There can be examples where a patient who suffered a CVA doesn’t have any neurologic deficits present.