General Surgery Coding Alert

 
Don't confuse late effects with complications: The two are not the same. "A complication describes a problem arising from a condition that still exits. A late effect on the other hand is caused by a condition no longer in its acute phase " Bucknam says. Certain conditions such as mal- or nonunion of fractures and scarring are inherent late effects regardless of when they occur. 2. Assign Late Effects as Secondary Diagnoses  When reporting late effects of an acute injury code the residual problem/condition as the primary diagnosis and record the appropriate late effects code as a secondary diagnosis according to section 1.7 of the Official ICD-9-CM Guidelines for Coding and Reporting.
 
For example a patient has serious third-degree burns on the left leg (945.55). As the wounds heal the patient experiences extensive scarring that requires treatment to relieve pain and restore full range of motion. Report the residual condition first (709.2 Other disorders of skin and subcutaneous tissue; scar conditions and fibrosis of skin) followed by the late effects code (906.8 Late effects of injuries to skin and subcutaneous tissues; late effect of burns of other specified sites) Fletcher says.
 
In a second example a trauma patient receives multiple injuries in an auto crash. Several months later the patient continues to have stomach problems prompted by the crash. In this case you would report the primary cause for the visit (for instance nonhealing wound pain ulcer etc.) followed by the late effects code that describes the reason for the injury (908.1 Late effect of internal injury to intra-abdominal organs). To add further specification you should also report the E code for late effects of motor vehicle accident E929.0.
 
Note: Be careful not to confuse the "late effect" E codes with the E codes for current motor vehicle accidents (E810-E819). 3. Follow Different Rules for Stroke Coding Coding for cerebrovascular accident (CVA) patients deviates from the general rule on coding late effects says Julie Jarvis CPC owner of Underwood Billing a coding and billing firm in Orlando Fla. When reporting late effects of stroke you need not report both the cause of the condition and the residual effect. Rather you should use a single ICD-9 code to describe late effects of CVA.
 
Codes describing late effects of stroke appear in a separate section (438.x) of the ICD-9 manual. These codes such as 438.11 (Late effects of cerebrovascular disease; aphasia) and 438.21 (... hemiplegia affecting dominant side) describe both the residual condition and the cause of the condition.
 
If the surgeon sees a patient with late effects of stroke you should report the late [...]