Neurology & Pain Management Coding Alert

Question: In our rehab clinic, we saw patient with stroke (cerebrovascular accident [CVA]) with hemisensory deficit. What ICD-9 diagnosis should I use?

New Jersey Subscriber

Answer: Because the neurologist specifically implies that the deficit is a late effect of CVA (patient is already on rehab), code this as 438.6 (Alterations of sensations). Code 438.6 requires an additional code to identify the altered sensation. Therefore, also code for the loss of sensation (sensory deficit) with 782.0 (Disturbance of skin sensation).

Hemisensory deficit is the loss of sensation on only one side of the body. This is a neurologic symptom seen even in the acute stages of a stroke often providing the neurologist with important clues as to the location on the brain of the stroke.