Home Health ICD-9/ICD-10 Alert

Question: We have a patient who was admitted from the hospital for rehab therapy following a stroke. Only PT and OT are ordered.
 
In coding the episode, should I list V57 in M0230 and abnormality of gait (781.2) and acute CVA (434.91) in M0240, with the acute CVA code (434.91) in M0245?

Answer: Because you're providing multiple aspects of care (PT and OT) related to the CVA, code the acute CVA first and then the residuals of the stroke. Before using abnormality of gait to justify the therapies, investigate the reason for the abnormal gait.
 
If the abnormal gait is the result of hemiplegia or hemiparesis, for example, then that code (342.xx) is a better choice than the symptom code. The 342.xx code would include a patient presenting with muscle weakness on one side or a dropfoot indicating mild hemiplegia.
 
In addition, abnormality of gait would probably not paint an accurate picture of the reason for PT and OT; the diagnosis of hemiplegia would more accurately portray the patient's situation.
 
In this scenario, you should code as follows:  434.91 (Cerebral artery occlusion, unspecified; with cerebral infarction), 342.xx (Hemiplegia and hemiparesis) V57.89 (Other specified rehabilitation procedure; other) or V57.1 (Other physical therapy) and V57.21 (Encounter for occupational therapy).
 
Another possibility: If the patient was receiving only one therapy discipline, then you should code that therapy first: V57.1, 342.xx and 434.91 in M0245.
 
Because a V code is being used correctly as primary in this case, you can use the acute CVA in M0245 for points and not use the 434.91 on the plan of care as a secondary diagnosis.
 
The acute CVA actually no longer exists, but you can still use it in M0230 or M0245 to get case mix points.

Reader questions were answered by Lisa Selman-Holman, JD, BSN, RN, CHCE, HCS-D, COS-C, consultant and principal of Selman-Holman & Associates in Denton, TX.