ED Coding and Reimbursement Alert

But double-check whether the patient had a hemorrhage

Just because you can list 434.91 in more situations doesn't mean you should ignore the details of the patient's stroke. Without specifics, procedures can be hard to justify.

Previously, for a simple diagnosis of -stroke,- the ICD-9 index listed 436 (Acute, but ill-defined, cerebrovascular disease) as the appropriate code, says Jackie Miller, RHIA, CPC, senior consultant at Coding Strategies Inc. in Dallas, Ga. Now the index lists 434.91 (Cerebral artery occlusion, unspecified, with cerebral infarction) as the code you should report. Under the new ICD-9 index, a diagnosis of -cerebrovascular accident- will also automatically translate to an occlusion with infarction, Miller says.

This listing means you may get paid for previously noncovered services for stroke patients. -There have been some scenarios in the past where there might be an ancillary denial for an interpretation of a CT or an MR- scan with a diagnosis of 436, but in which you would receive payment with 434.91, Miller says.
 
Don't Stop Documenting Details You should still encourage doctors to write down precise diagnoses, says consultant Sandy Nicholson with Pershing Yoakley & Associates in Atlanta. Now, physicians can get away with writing down -stroke- without going into more detail--and that means you could be missing out on details of the diagnosis that could justify the procedures the physician performed.

For example, if the patient has a stroke with cerebral hemorrhage and the physician fails to note this complication, it could vastly understate the seriousness of the patient's condition, Nicholson says. -Embolic strokes have one-fifth the mortality rate of hemorrhagic strokes,- she says. Also, if other providers don't realize the patient has a hemorrhage and they start him on coumadin or aspirin, he could die.

If the physician specifies that the patient has a hemorrhage, the coder would use ICD-9 code 431 (Intracerebral hemorrhage), Miller says. Medicare will cover some procedures for a stroke with hemorrhage, but it won't cover certain procedures for a stroke without hemorrhage, such as surgical or transcatheter interventions.