Internal Medicine Coding Alert

Question: A skilled nursing facility resident is receiving care for late effects of a cerebrovascular accident, and her internist transfers her to the hospital for treatment of pneumonia. When the patient returns to the SNF, she is still receiving antibiotics for the pneumonia, but the main reason she is returning to the SNF is for help with late effects of the CVA. Which diagnosis should I list first--pneumonia or late effects of CVA?


Texas Subscriber

Answer: You should first assign a code from category 438.x (Late effects of cerebrovascular disease), according to Coding Clinic. And, as long as you're providing treatment for pneumonia, you can list the appropriate pneumonia code as a secondary diagnosis.