Home Health ICD-9/ICD-10 Alert

Late effect of CVA turns guidelines upside down.

A late effect is the condition produced after the acute phase of an illness or injury has run its course, according to the ICD-9-CM Official Guidelines for Coding and Reporting.

There is no time limit on when you can report a late effect code, but the acute condition does need to be resolved, says consultant Pam Warmack with Clinic Connections in Ruston, La. Some residual effects appear early on, such as when a patient has had a cerebrovascular accident (CVA) but in other cases the residual effect may not show up until months or years later, such as when your patient has had a previous injury.

When coding for a late effect, you'll generally need to list two codes, says Sharon Molinari, RN, HCS-D, COS-C, a home health consultant based in Henderson, Nev. For most late effects, you'll list the presenting problem first, followed by the late effect code, she says.

For example: Your patient has traumatic arthritis due to an old ankle fracture. The original fracture was treated, and you are now providing care for the late effect of arthritis. To code for this patient, Molinari says you would list the following:

• 716.17 (Traumatic arthropathy; ankle and foot) and
• 905.4 (Late effect of fracture of lower extremities).

CVAs are the first exception to late effects coding guidelines. When coding for the late effects of a CVA, you'll often need only one code, Molinari says. Many  codes in the 438.x (Late effects of cerebrovascular disease) category combine the presenting problem with the late effect in one code, she says.

For example: 438.22 (Late effect cerebrovascular disease, hemiplegia, non-dominant side).

Exception 2: Mind the Notes -- List 2 Codes for Some CVA Late Effects

Upside down: Watch for "use additional code" notes in the 438.x section of your coding manual. In these situations, you will sequence your codes in reverse order than you would for other late effects: You'll code the late effect code first, followed by the residual or presenting problem.

Why the difference? The coding guideline for combination codes states, "When the combination code lacks necessary specificity in describing the manifestation or complication, an additional code should be used as a secondary code." That means that you should add the code that provides more specificity about the nature of the residual, says Lisa Selman-Holman, JD, BSN, RN, HCS-D, COS-C, consultant and principal of Selman-Holman & Associates and CoDR -- Coding Done Right in Denton, Texas.

For example: When coding for a vision disturbance as a late effect of stroke, you're required to list an additional code to describe the type of disturbance along with the combination code 438.7 (Late effects of cerebrovascular disease; disturbances of vision). If your patient is experiencing blurred vision as a late effect of stroke, you would list 438.7 followed by 368.8 (Blurred vision, NOS), Molinari says.

Another example: If you're coding for the residual of a stroke and there is no ICD-9 combination code for it, you would list 438.89 (Other late effects of cerebrovascular disease), followed by a second code to identify the specific late effect. So, if your patient has generalized muscle weakness as the late effect of a stroke -- not the more specific condition monoplegia (438.4x) or hemiplegia (438.2x). You would list 438.89 and then 728.87 (Muscle weakness [generalized]).

Manifestations are the final exception in late effect coding. When the residual you're coding for is designated as a manifestation code, you'll need to follow manifestation coding guidelines.

Manifestation coding rules trump other rules. So, when coding for manifestations, you must sequence the underlying etiology first, followed by the manifestation code.

For example: Your patient has curvature of the spine as a late effect of rickets. For this patient, Molinari suggests coding 268.1 (Rickets, late effect) first, followed by 737.40 (Curvature of spine, associated with other conditions; unspecified). The 737.40 code is one of those manifestation codes listed in the tabular list in italics.