Neurosurgery Coding Alert

The additional digits call for more details and documentation.

The current ICD-9-CM gives you a choice to report the late effects of cerebrovascular disease with codes 438.xx (Late effects of cerebrovascular disease), depending upon the consequences of the cerebrovascular disease. You can choose from codes describing cognitive or speech/language deficits, hemiplegia, vision disturbances, and others.

Bone Up on ICD-9 Codes

Look at the table below to catch up on the ICD-9 codes 438.0 to 438.9.

What's missing: ICD-9-CM codes do not specify the underlying etiology or laterality. ICD-10 will change that with new terminology, etiology details, and anatomic references.

Changes: Diagnoses related to late effect of cerebrovascular disease will be in code block I69.xx (Sequelae of cerebrovascular disease) under ICD-10. The term "sequelae" has historically been used in ICD-10. Sometimes a patient's current condition is caused by an original condition or injury that is no longer present. One is said to be the sequela (late effect) of the other. You'll have more than 150 code choices distinguished by underlying etiology (such as nontraumatic subarachnoid hemorrhage, nontraumatic intracerebral hemorrhage, cerebral infarction, unspecified cerebrovascular diseases, and more). Sixth digit choices will indicate dominant and non-dominant, as well as right and left sides when applicable.

Example: Diagnosis I69.341 describes monoplegia of the patient's lower limb following cerebral infarction affecting the right dominant side. In the same code block, diagnosis I69.343 describes monoplegia of the lower limb following cerebral infarction affecting the right nondominant side.

Prepare: Start educating your surgeons now about how much more detailed their documentation, including the affected side and whether it is the patient's dominant or non-dominant side, will need to be for ICD-10. Begin implementing some trial audits based on ICD-10 coding guidelines to help gauge how well you're currently doing and next steps you might need to take.