Internal Medicine Coding Alert

Why the rules change when you report a stroke's 'late effects'

Heads up, coders: When you report the "late effects" of cerebrovascular accident (CVA) or stroke, all you need is one code to describe the condition's cause and effect.

Why CVA Is an Exception to the Rules

Many internal medicine coders incorrectly assume that if a patient has late effects of CVA, they should follow traditional late-effects coding rules and use two codes to report the cause of the condition along with the residual effect.

Right way: Remember that reporting a stroke's late effects deviates from this coding rule, because all you need is one primary diagnosis code. You should choose the appropriate code in a separate section (438.x) of the ICD-9 manual. These codes, such as 438.11 (Late effects of cerebrovascular disease; aphasia) or 438.21 (... hemiplegia affecting dominant side), describe both the cause and the effect.

For example: A 78-year-old patient who had CVA in 2002 develops residual hemiplegia that affects his nondominant side. So, you would assign 438.22 (... hemiplegia affecting nondominant side), says Bruce Rappoport, MD, CPC, a board-certified internist who works with physicians on compliance, documentation, coding and quality issues for Rachlin, Cohen & Holtz LLP, a Fort Lauderdale, Fla.-based accounting firm with healthcare expertise. The residual deficit defines which ICD-9 code is most appropriate, he says.

Report New CVA Cases First

Be careful that you don't report a code from the 438.x series for all CVA diagnoses. If a patient has another CVA, you should report the new condition first, followed by the appropriate late-effects code.

Why: You should report the new and previous CVA this way to identify current CVA complications, while describing pre-existing conditions as well, coding experts say.

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. 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 ICD-9 guidelines.