Neurology & Pain Management Coding Alert

When your neurologist sees a patient who had a stroke, either recently or in the distant past, he may record a number of different conditions -- which makes your job more difficult. If you remember a few guidelines, you'll select the proper ICD-9 codes for every cerebrovascular accident (CVA) case your neurologist treats.

When your neurologist sees a patient who has had a stroke, or CVA, he may document multiple deficiencies, both new and lingering. When the patient presents with speech and language deficits you have two diagnosis codes to choose from.

To help both differentiate the etiology of speech and language deficits, and to add specificity to those deficits, ICD-9 2010 includes two cerebrovascular disease lateeffects codes: 438.13 (Late effects of cerebrovascular disease, speech and language deficits, dysarthria) and 438.14 (..., fluency disorder [stuttering]).

If you are not aware of the "combined" ICD-9 late effects codes often you might misreport the ICD-9 code(s) indicating that the patient has the active or ongoing condition, in this case a CVA, rather than reporting the compliant late effect code.

Example: Your neurologist sees a patient who suffered a stroke three years ago and has subsequent hemiplegia on her right (dominant) side. In this case, you may report 434.91 (Cerebral artery occlusion, unspecified, with cerebral infarction) and 342.91 (Hemiplegia, unspecified, affecting dominant side) in error as if the patient is actively being treated for a current occlusion and hemiplegia rather than reporting the correct combined late effects code, 438.21 (Late effect of cerebrovascular disease; Hemiplegia affecting dominant side), says Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACSPM, CHCO, owner of MJH Consulting in Denver.

Coding for CVA patients is done somewhat differently than coding late effects from other conditions, such as a spinal cord injury from an accident.

Key: When reporting late effects of a stroke, you only need to use a single ICD-9 code to describe the late effects or manifestations of the CVA, rather than report two ICD-9 codes -- one for the residual effect and one for the condition's cause or as sometimes referenced as the etiology of the manifestation.

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 manifestation and the etiology of the condition.

"A late effect is any residual effect that ensues from the original injury and/or condition and can be coded as such at any time after the onset of the condition," says Claudia Kernaghan, CPC, coder for Nevada Imaging Centers in Las Vegas.

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.

Warning: 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.

To determine if a condition is a late effect, you should look in your neurologist's documentation for keywords such as:

• 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."

There can be instances where a patient who suffered a CVA does not have any neurologic deficits present. In those cases you should look to V12.54 (Personal history of transient ischemic attack [TIA], and cerebral infarction without residual deficits). You'll report this code when the documentation indicates the patient had a stroke without any residual effects.

Example: A patient presents for another problem, but has a history of transient ischemic attack (TIA). If you report 435.9 (Unspecified transient cerebral ischemia; Impending cerebrovascular accident; Intermittent cerebralischemia; transient ischemic attack [TIA]), it would appear that the patient has TIA as an active condition. In this case, V12.54 would be the correct code.

"Many coders don't realize that there is a V code to indicate that the patient has a history of TIA or stroke without sequelae," Hammer says.

Final reminder: Only report a diagnosis supported by documentation. You should never assign an ICD-9 code merely for the purpose of achieving payment by falsely claiming medical necessity. This is fraudulent, which can result in serious financial and criminal consequences, and can harm patient outcomes.