Internal Medicine Coding Alert

The key issue in determining whether an aftereffect of a stroke has become a late effect is the patient's stage in the recovery process.

The ICD-9 book notes that a late effect is a "residual effect (condition produced) after the acute phase of an illness or injury has terminated."

This residual effect may be apparent immediately after a CVA or may become evident later, says Barbara Pross, CPC, CMPM, a consultant with DoctorsManagement in Knoxville, Tenn. Any problem for example, slurred speech that resolves itself before the patient leaves the hospital is not a late effect because it ends during the acute phase.

"Don't presume that anything is a late effect," says Shawn R. Hafer, CCS-P, CPC, a consultant with the Twin Falls, Idaho-based Brown Consulting Associates Inc. She says coders should not determine themselves that a condition is a late effect, because that information should come from the physician. To ensure proper coding of late effects of CVA, Hafer recommends that internal medicine offices add the 438 code series to their patient discharge forms. That gives physicians an easy way to document that a late effect has occurred.