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Internal Medicine Coding Alert

One Code Tells the Story When Detailing Late Effects of CVA

Published on Mon Jul 01, 2002

It's easy to get tripped up when coding the late effects of a cerebrovascular accident (CVA) or stroke, because the process differs from that used to code late effects of most other injuries and illnesses. The secret: Use a code from the 438 series in the ICD-9 manual to code both the late effect from the CVA and the cause of the late effect.

Stroke Coding Breaks the Rule

CVA patients are an exception to the general rule on coding late effects. "Most of the time, when you are coding late effects, you will use two codes," says Shawn R. Hafer, CCS-P, CPC, a consultant with the Twin Falls, Idaho-based Brown Consulting Associates Inc.

The general rule is that you first code the residual effect and then add a second code that details the cause of the condition, Hafer says. When the late effect is related to an injury or poisoning, you also use an E code.

However, the ICD-9 manual lists several exceptions to the two-code rule, one of which applies to CVAs. The manual says you should assign one code describing both the residual condition and the cause in cases when the late effects code has been expanded to a fourth or fifth digit that describes the residual condition.

"The CVA section is, to my knowledge, the only section that has expanded to fourth and fifth digits to include both the late effect and the cause," Hafer says.

Late Effects Describe Lasting Effects of CVA

A late effect is a residual condition that a patient still has after the acute phase of an injury or illness has ended. Examples of late effects from a CVA include speech difficulties or paralysis.

The internist will use the late effects codes with CVA patients primarily in two situations:

  • The CVA patient sees the physician for a complaint related to the late effect.

    In this case, code the late effect as the primary diagnosis. For example, a patient sees the internist concerning continued paralysis of an arm three months after a CVA. Use code 438.30 (Late effects of cerebrovascular disease; monoplegia of upper limb affecting unspecified side).

  • The patient is admitted for treatment of another CVA.

    In this scenario, code the appropriate late effects code as a secondary diagnosis. This identifies those deficits that are related to the present CVA and those that were pre-existing conditions. For example, a patient who has impaired speech as a result of a previous subdural hemorrhage is admitted with acute cerebral thrombosis. Code the current condition first, using 434.0x (Cerebral thrombosis), and use as a secondary diagnosis 438.12 (Late effects of cerebrovascular disease; dysphasia). If the patient has no residual problems from the first CVA, use V12.59 (Diseases of circulatory system; other) to indicate a history of cerebrovascular disease with no neurological deficits.

    Late effects codes are not used when a patient is discharged from the hospital after being treated for a stroke. Instead use the correct code from the 430-437 series (Cerebrovascular disease) to describe the CVA (e.g., 434.0x) and use the ICD-9 codes that denote the impairments that the patient still has. For example, if the patient is paralyzed on one side of the body, code a secondary diagnosis of 342.90 (Hemiplegia, unspecified, affecting unspecified side).

    Add a Code to Describe Unnamed Conditions

    Two of the codes in the 438 series require a second code, says Barbara Pross, CPC, CMPM, a consultant with DoctorsManagement in Knoxville, Tenn.:

  • 438.89 (Other late effects of cerebrovascular disease). When the patient's residual condition is not listed, use this code with a second code to provide further detail. For example, use 438.89 followed by 596.59 (Other functional disorder of bladder) for a patient who is incontinent as a result of a CVA.

  • 438.5x (Late effects of cerebrovascular disease; other paralytic syndrome). When the patient has a paralytic syndrome not specified in the 438 series, use 438.5 along with a fifth digit and another code, such as 344.00-344.09 (Quadriplegia and quadriparesis), to indicate the paralysis type.

    Get Up-to-Date on Late Effects Codes

    Many providers are improperly coding late effects as acute conditions but coders can solve that problem by brushing up on their late effects codes.

    "Many providers are not aware of this category of codes, and some coders are not either," Hafer says.

    Hafer recommends that coders educate their providers about the existence of these codes, but she also warns that the codes are appropriate only in limited circumstances. "When coders discover this category, they tend to overuse it," Hafer says.

    Kristine D. Eckis, CMM, CPC, owner of Bottom Line Medical Administrative Consultants Inc., in Lake Wales, Fla., says coders should look for key words in the doctor's dictation to differentiate between acute problems and late effects.

    "A coder can pick up on a doctor's clues and determine that [a condition] might be a late effect," Eckis says.

    Words such as "late," "old," "due to," and "following" all are hints that a late effects code might be appropriate, she says.

    Hafer gives two examples of proper late effects coding:

  • Paralysis of the right leg due to poliomyelitis 50 years ago. Code 344.30 (Monoplegia of lower limb; affecting unspecified side) plus 138 (Late effects of acute poliomyelitis).

  • Traumatic arthritis of the ankle due to an old fracture in the ankle joint. Code 716.17 (Traumatic arthropathy; ankle and foot) plus 905.4 (Late effect of fracture of lower extremities).

    It is important that offices properly code the late effects of an illness or injury for the patient's record and for insurance reasons, Pross says.

    "If you don't code the late effect, no one is going to know it's from the injury," she notes. "It's just good documentation."

    Tip: Use late effects codes to describe residual effects from a wide variety of illnesses and injuries, including poisonings, burns, sprains and fractures. To find the categories where late effects codes apply, search the alphabetical index in your ICD-9 book using the key term "late" and the subterm "effects."

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