Neurosurgery Coding Alert

Watch terms and deficits to choose legitimate codes.

Neurosurgery coders who overlooked the cerebrovascular accident section changes in the updated ICD-9 guidelines, effective Oct. 1, could be risking denials and delays for procedures which include CVA codes. Regain lost ground with these pointers on diagnosis changes that could affect neurosurgery claims.

Note: Not all 2011 ICD-9-CM books include the updated guidelines because the books went to printer before the updated guidelines became available. Read on for the basic information your practice needs to know, however, then check out the full guidelines at www.cdc.gov/nchs/data/icd9/icdguide10.pdf.

Check Your Terminology

Patients -- and practitioners -- sometimes use the terms "stroke" and "CVA" (cerebrovascular accident) interchangeably to refer to a cerebral infarction. The terms "stroke," "CVA," and "cerebral infarction NOS" each fall under diagnosis 434.91 (Cerebral artery occlusion, unspecified; with cerebral infarction).

The updated guidelines add, "Additional code(s) should be assigned for any neurological deficits with the acute CVA, regardless of whether or not the neurologic defect resolves prior to discharge."

Example: Some neurologic deficits your neurosurgeon might document in addition to the acute CVA include 784.59 (Other speech disturbance) for slurred speech, 331.83 (Mild cognitive impairment, so stated), 799.53 (Visuospatial deficit), or 342.01 (Flaccid hemiplegia and hemiparesis, affecting dominant side). Don't Mix Late Effects With Neurological Deficits Diagnoses under ICD-9's category 438 deal with the late effects of cardiovascular disease.

Definition: A late effect is the residual effect (condition produced) after the acute phase of an illness or injury has terminated, says Marvel Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, owner of MJH Consulting in Denver. "There is no time limit on when you can use a late effect code," Hammer says. "The residual may be apparent early, such as in cerebrovascular accident cases, or if may occur months or years later, such as those due to a previous injury." According to 2010 ICD-9 guidelines, you turn to 438.xx when indicating conditions in categories 430-437 as the cases of late effects. These late effects include neurological deficits that persist after the initial onset of conditions in categories 430- 437, such as speech and language deficits (438.1x), dysphagia (438.82), or vertigo (438.85).

Change: Guidelines effective Oct. 1 specify using codes in category 438 only for late effects of cerebrovascular disease, not for neurological deficits associated with an acute CVA. Example: If your neurosurgeon notes that the patient has a facial droop as a late effect of his CVA two years ago, you would code 438.83 (Other late effects of cerebrovascular disease, facial weakness). According to the updated HIPAA mandated guidelines, however, your coding changes if the patient is in the acute phase of the stroke as documented by your surgeon. In that situation, you would report 781.94 (Facial weakness) for the facial droop. Clear documentation by your neurosurgeon is the key to following the updated guidelines.

Remember Diagnosis Signals Disease

Guidelines under Section 1 C.18.d.3 differentiate status and history diagnosis codes. The guideline update clarifies what status codes represent: "Status codes indicate that a patient is a carrier of a disease, has the sequelae or residual of a past disease or condition, or has another factor influencing a person's health status."

A status code (such as V58.61, Long-term [current] use of anticoagulants) informs healthcare providers and insurers of the patient's condition, and might affect the course of treatment and its outcome. Reporting a personal history code (such as V12.41, Personal history of benign neoplasm of the brain) explains a patient's past medical condition that no longer exists and is not receiving any treatment. The code also indicates that the patient has the potential for recurrence, however, and therefore might require continued monitoring.

Final note: Always verify that you assign the correct status code for a patient because of the potential impact the diagnosis could have on future treatments. "It's always good to accurately report ICD-9 codes, as they may help 'explain' the medical necessity for diagnostic tests, procedures, etc.," Hammer adds.