Neurology & Pain Management Coding Alert

If you code for a facility that receives a stroke patient, don't miss a crucial ICD-9 2009 change. Until now, patients treated at one facility with tPA (tissue plasminogen activator) and then moved to another facility made for difficult coding. Sharpen your coding pencil, because a new code taking effect on Oct. 1 should make your job a little easier.

"The American Academy of Neurology (AAN) is requesting a unique code to indicate that a patient has received tissue plasminogen activator for a stroke," says a bulletin from the Centers for Disease Control and Prevention (CDC).

Prior to the request for a new code, there was no way to indicate that a stroke patient had received intravenous tissue plasminogen activator (IV tPA), which is a treatment approved by the Food and Drug Administration (FDA) for treatment of acute stroke patients.

Why the change? Rural hospitals, or hospitals not having a support system to handle complications associated with stroke, would often transfer patients directly from the emergency department to another hospital for critical care after initiating an IV tPA, a procedure commonly called "drip and ship." Monitoring of how frequently this occurs will be critical in assessing the allocation and organization of resources for acute stroke care within the U.S. healthcare system, say Joseph P. Broderick, MD, and Dawn Kleindorfer, MD, in a proposal to the CDC. Both physicians represented the American Academy of Neurology (AAN) in pursuit of
the change.

"Use of rt-PA in smaller community and rural hospitals is increasing because of support relationships with regional comprehensive stroke centers, similar to trauma models of care," Broderick and Kleindorfer say in their proposal to the CDC.

Quick note: For coding purposes, tPA is also known as rtPA, or recombinant tissue plasminogen activator. If you encounter one or the other in your neurologist's documentation, don't worry -- they are synonymous in terms of how you should code.

CMS approved the following update to V45.8 (Other postprocedural status):

V45.88 -- Status post administration of tPA (rtPA) in a different facility within the last 24 hours prior to admission to current facility.

CMS instructions are to first code the condition requiring tPA administration, such as acute cerebral infarction (433.0-433.9 with fifth-digit 1 or 434.0-434.9 with fifth digit 1).

So, you should assign V45.88 as a secondary diagnosis when the patient is transferred into another facility, and your neurologist's documentation indicates the patient received tPA within the last 24 hours prior to admission to the current facility. Remember, V45.88 is only applicable to the receiving facility record and not to the transferring facility record.

Resource: The HIPAA mandated "ICD-9-CM Official Guidelines for Coding and Reporting" further clarify V45.88 use at: http://www.cdc.gov/nchs/datawh/ftpserv/ftpicd9/icdguide08.pdf.

According to the guidelines, "This applies even if the patient is still receiving the tPA at the time they are received into the current facility."