Home Health ICD-9/ICD-10 Alert

Question: We admitted a patient for physical therapy and occupational therapy after a three-day hospital stay for a stroke. He has late-effect hemiplegia. He also has hypertension. How should I code?

Answer: To code this patient more specifically you will need to know which side is affected and whether that side is the dominant or non-dominant side. Because the patient is receiving services from rehab only, code as follows:

• V57.89 (Multiple training or therapy);

• 438.20 (Late effects of cerebrovascular disease; hemiplegia affecting unspecified side) and

• 401.9 (Essential hypertension; unspecified).

You may also place the 438.XX code in M0246 across from the V57.89 code.