Neurology & Pain Management Coding Alert

Find out what codes you should use for the most common CVA late effects

You could be submitting inaccurate information and possibly compromising your practice's bottom line by not properly coding late-effects diagnoses.
 
Using these codes doesn't have to be confusing when you use these five simple strategies.

Strategy 1: Define Late Effects

You can build a solid foundation by learning the in's and out's of what late effects really are.
 
What they are: Late effects are the long-term effects of an injury or illness after the acute phase is over. For example, a patient may have a vertebral fracture and continue to have pain years after the fracture heals. Some late effects present early, while others might only become apparent months or years later. -There are no time limits for late effects,- says Linda Becker, RN, CMC, physician office manager at Madonna Rehabilitation Hospital in Lincoln, Neb.
 
The ICD-9 manual provides a separate subsection (905-909) describing -late effects of injuries, poisonings, toxic effects, and other external causes.- Late effects that neurologists commonly see include, for example, 905.0-905.9 (Late effects of musculoskeletal and connective tissue injuries), 907.0-907.9 (Late effects of injuries to the nervous system) or 908.6 (Late effect of certain complications of trauma).
 
Late effects tell the whole story of a patient's condition, and they present a much clearer picture to the carrier of why a physician may choose to treat a patient in a particular way, says Terry Fletcher, BS, CPC, CCS-P, CCS, CMSCS, CMC, a coding and reimbursement specialist in Laguna Niguel, Calif. Specifically, late effects codes link what is going on with the patient now with what happened in the past.
 
-Like E codes for external causes of injury and poisoning, late effects codes provide a more complete picture of the reason for treatment and can become an issue for patients who are injured in an auto accident or in workers- compensation claims,- Fletcher says.
 
-Our outpatient clinic sees patients with residual problems from spinal cord injuries, traumatic brain injuries, and orthopedic injuries as well as conditions such as cerebral vascular accident (CVA),- Becker says. -We use a wide range of late effects codes daily.-

Strategy 2: Home In on These Keywords

To determine if a condition is a late effect, you should look for keywords in the physician's documentation. According to Becker, such keywords might include:
 
- due to -- such as -pain in right hip due to fracture last year-
 
- following -- such as -personality changes following a brain injury in 1996-
 
- as a result of --  such as -hemiplegia as a result of CVA-
 
- residual effect --  such as -arthritis that is a residual effect of previous hip fracture.-

Heads up: Don't confuse late effects with complications. A complication is typically associated with a difficulty or problem that occurs with a specific procedure (996.xx) and not a condition due to the original disease or injury.

Strategy 3: See How Secondary Diagnoses Work

When you report late effects of an acute injury, your primary diagnosis should be the residual problem condition. You should list the appropriate late effects code as a secondary diagnosis, according to section 1.B.12 of the Official ICD-9-CM Guidelines for Coding and Reporting.
 
For example, a patient injures his spinal cord in an auto accident. Some months later, the patient has pain and motor disturbance related to the previous injury and consults with the neurologist for testing and treatment. In this case, you should first report the spinal cord injury (for example, 952.x, Spinal cord injury without evidence of spinal bone injury) -- even though the acute phase of the injury has passed -- and the late effects (907.2, Late effect of spinal cord injury) as a secondary diagnosis.
  
Reporting only the spinal cord injury would suggest that it is a new, acute injury. But by appending the late effects code, you indicate the presence of problems resulting from the previous injury.

Strategy 4: Find Out How Stroke Coding Differs

Coding for CVA patients deviates from the general rule for coding late effects.
 
Key: When reporting late effects of a stroke, you need not report both the condition's cause and the residual effect. Rather, you should use a single ICD-9 code to describe CVA late effects. -There are codes specifically assigned to the most common late effects of CVA,- Becker says.
 
Codes describing late effects of stroke appear in a separate section of the ICD-9 manual (438). These codes, such as 438.11 (Late effects of cerebrovascular disease; aphasia) and 438.21 (Hemiplegia affecting dominant side), describe both the residual condition and the cause of the condition.
 
Example 1: A patient is concerned about continued arm paralysis three months after a CVA and consults with your neurologist. You should report the late effect as the primary diagnosis. Therefore, you should report 438.30 (Monoplegia of upper limb affecting unspecified side) as the primary diagnosis.
 
Example 2: On the other hand, if the physician admits the patient for treatment of another CVA (new diagnosis), you should report the current CVA first (the 436 category), followed by any appropriate late effects code(s) (such as 438.30). This identifies those deficits that relate to the present CVA and from pre-existing conditions.
 
-If a patient has a current CVA and deficits from an old CVA, ICD-9 guidelines state that you may use  codes from category 438 with codes from 430-437,- says Janet O-Connor, CPC, assistant billing manager at University of Virginia Physical Medicine and Rehab in Charlottesville.
 
Example 3: 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 Section 1.C7.B of the guidelines.

Strategy 5: Describe Unnamed CVA Conditions

Two codes in the 438 series require you to add a secondary code -because they are nonspecific and you need another code to be as specific as possible,- Becker says.
 
The first is 438.89 (Other late effects of cerebrovascular disease). When ICD-9 does not list the patient's residual condition, use this along with a second code to provide further detail.
 
For a patient who has urinary incontinence due to CVA, you should report 438.89 followed by 596.59 (Other functional disorder of bladder) and 788.39 (Other urinary incontinence).
 
The second code in this category is 438.5x (Other paralytic syndrome). ICD-9 may not specify the patient's paralytic syndrome in the 438 series, so you might use 438.5x and another code, such as 344.00-344.09 (Quadriplegia and quadriparesis), to indicate the type of the patient's paralysis.
 
Note: You can find the official ICD-9-CM Guidelines for Coding and Reporting at www.cdc.gov/nchs/data/icd9/icdguide.pdf.