MDS Alert

The scenario: A resident with severe type 1 diabetes underwent an amputation and was set to go to a nursing home for rehab therapy related to the amputation. Two days before discharge from the hospital, however,  the person suffered a massive stroke, resulting in hemiplegia, aphasia, and dysphagia, requiring placement of a Gtube. The person also had cognitive impairment and was difficult to arouse.The person did go a week  later to the nursing home for PT, OT, and speech therapy. At that time, he was still difficult to wake up to participate in the therapies, and he had limited motor skills. What should be the first-listed diagnosis?

Answer: Due to the complexity of the resident's medical conditions and the fact that his therapy minutes were initially limited, the first listed diagnosis in the medical record and the UB-04 would be a category code   438 for late effects of a stroke, says Charlotte Lefert, RHIA, an independent health information management consultant in Madison, Wis., and coding strategy facilitator for the LTC Community of Practice for the American Health Information Management Association. You wouldn't list V57, as "it can only be a first-listed diagnosis." In cases where therapies won't be assigned an ICD-9-CM code, it's recommended that staff "free-text" on the diagnosis list: "LE CVA w/ hemiplegia (w/ therapies)," says Lefert.