Neurology & Pain Management Coding Alert

Coding the late effects of a cerebrovascular accident (CVA, or stroke) differs from that used to report late effects of most other injuries and illnesses. In particular, you should select just one code from ICD-9's 438 series to describe both the late effect from the CVA and the cause of the late effect.

Coding for CVA patients deviates from the general rule for coding late effects, says Julie Jarvis, CPC, owner of Underwood Billing, a coding and billing firm in Orlando, Fla. Coders are familiar with listing two codes the residual effect and the cause of the condition on the claim form when coding late effects, but this isn't correct when stroke causes the late effects.

The ICD-9 manual includes a separate section (438.x) that lists the late effects of cerebrovascular disease. These codes, such as 438.11 (Aphasia as late effect of cerebrovascular disease) describe both the residual condition and the cause.

A late effect is a residual condition that lingers after the acute phase of an injury or illness has ended. Examples of late effects from a CVA include speech difficulties (438.1x) or paralysis (438.2x-438.5x). Physicians normally apply such codes in two situations:

1. The CVA patient sees the physician for a late effect-related complaint. In this case, report the late effect as the primary diagnosis. For example, a patient sees the neurologist concerning continued arm paralysis three months after a CVA. Use 438.30 (Late effects of cerebrovascular disease; monoplegia of upper limb affecting unspecified side).

2. The physician admits the patient for treatment of another CVA. In this scenario, code the current CVA first, followed by the appropriate late effects code. This identifies those deficits that relate to the present CVA and those associated with pre-existing conditions.

For example, the physician admits a patient with acute cerebral thrombosis. The patient previously had a stroke, which left her with impaired speech. In this case, you should code the current condition first, using 434.0x (Cerebral thrombosis), and add 438.12 (Late effects of cerebrovascular disease; dysphasia) as a secondary diagnosis, Jarvis says. If the patient has no residual problems from the first CVA, report V12.59 (Personal history of certain other diseases of circulatory system; other) as the second diagnosis, according to ICD-9.

Do not use late effects codes when reporting a patient's hospital discharge after stroke treatment, Jarvis says. Instead, you should report 436 (Acute, but ill-defined, cerebrovascular disease) to describe the CVA along with the ICD-9 codes that denote the impairments that the patient still has. For example, if the patient is paralyzed on one side of the body, report 342.90 (Hemiplegia, unspecified, affecting unspecified side) as the secondary diagnosis code following 436.

Two codes in the 438 series require you to add a secondary code. 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 instance, report 438.89 followed by 596.59 (Other functional disorder of bladder) for a patient who is incontinent due to CVA.

The second code in this category is 438.5x (Late effects of cerebrovascular disease; other paralytic syndrome). When ICD-9 does not specify the patient's paralytic syndrome in the 438 series, Jarvis advises using 438.5x and another code, such as 344.00-344.09 (Quadriplegia and quadriparesis), to indicate the type of the patient's paralysis.

Some physician practices erroneously code late effects as acute conditions. If your practice sees a lot of stroke patients, list the late effect code series (438.x) on your superbills so the physicians and office staff are aware of them. To determine if a condition is a late effect, says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for CRN Institute, an online coding certification training center based in Absecon, N.J., look for key words in the documentation, such as "late," "old," "due to," "caused by" or "following."