Home Health ICD-9/ICD-10 Alert

Question: The physician wrote on the order for our new patient "poor vision secondary to cerebrovascular disease." How would I code for this?

Answer: When coding for late effects of cerebrovascular disease, look to category 438.x (Late effects of cerebrovascular disease). When the physician indicates that the patient has a late effect, sequelae, or, as in your scenario, a condition secondary to cerebrovascular disease, you'll find your code in the 438.x section.

Late effects can occur at any time after the onset of the causal condition, so there's no time limit on when you can report a code from the 438.x category.

In your example, use 438.7 (Disturbances of vision) to report that your patient has a late effect of cerebrovascular disease.

In the notes following 438.7, your coding manual instructs you to list an additional code to identify your patient's visual disturbance.

In your patient's case, list 369.9 (Unspecified visual loss) unless you can obtain more specific information regarding the visual loss.