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 effect as the primary diagnosis. For example a patient is concerned about continued arm paralysis three months after a CVA and consults with the surgeon. In this case report 438.30 (... monoplegia of upper limb affecting unspecified side) as the primary diagnosis.
 
But if the physician admits the patient for treatment of another CVA you should report the current CVA first followed by any appropriate late effects code(s). This identifies those deficits from the present CVA and those from pre-existing conditions.
 
For example the physician admits a patient with acute cerebral thrombosis. The patient previously had a stroke which left her with impaired speech. Code the current condition first using 434.0x (Cerebral thrombosis) and add 438.12 (... dysphasia) as a secondary diagnosis Jarvis says. If the patient has no residual problems from the first CVA you may report V12.59 (Personal history of certain other diseases of circulatory system; other) as the secondary diagnosis according to Section 1.7 of ICD-9.

Describe Unnamed CVA Conditions

Two codes in the 438 series require you to add a secondary code. The first is 438.89 (Other late effects of cerebrovascular disease). When ICD-9 does not list the patient's residual condition use this along with a second code to provide further detail. For instance report 438.89 followed by 596.59 (Other functional disorder of bladder) for a patient who is incontinent due to CVA.
 
The second code in this category is 438.5x (Late effects of other paralytic syndrome). When ICD-9 does not specify the patient's paralytic syndrome in the 438 series Jarvis advises using 438.5x and another code such as 344.00-344.09 (Quadriplegia and quadriparesis) to indicate the type of the patient's paralysis.

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