Neurosurgery Coding Alert

More detail means better claims success, experts say

If you're overlooking late effects when assigning ICD-9 codes, you're providing incomplete information and possibly compromising both quality of patient care and physician reimbursement. Fortunately, recognizing and reporting late effects can be simple when you know what to look for.

Understand Why Late Effects Matter

Late effects are the long-term effects of, or conditions produced by, an injury or illness whose acute phase has passed. For example, a patient may have a vertebral fracture and continue to have pain years after the fracture has healed. Some late effects present early, while others might only become apparent months or years later. "There are no time limits for late effects," says Marcella Bucknam, CPC, CCS-P, CPC-H, CCA, HIM program coordinator at Clarkson College in Omaha, Neb.
 
The ICD-9 manual provides a separate subsection (905-909) describing "Late Effects of Injuries, Poisonings, Toxic Effects, and Other External Causes." Late effects that neurosurgeons commonly see might include 905.0-905.5 (Late effect of fracture ...), 907.0-907.9 (Late effects of injuries to the nervous system) or 908.6 (Late effect of certain complications of trauma).
 
Late effects tell the whole story of a patient's condition and present a much clearer picture to the carrier of why a physician may choose a particular treatment, says Terry Fletcher, BS, CPC, CCS-P, an independent coding and reimbursement specialist in Dana Point, Calif. Specifically, late effects codes link the patient's current condition with what happened in the past. "Like E codes for external causes of injury and poisoning, late effects codes provide a more complete picture of the reason for treatment and can become an issue for patients who are injured in an auto accident or in workers' compensation claims," Fletcher says.
 
To determine whether a condition is a late effect, you should look for keywords in the physician's documentation such as "late," "old," "due to," "caused by" and/or "following." "Paralysis due to stroke," for instance, is a clear indication of a late effect of a cerebrovascular accident (CVA).
 
Don't confuse late effects with complications. The two are not the same. "A complication describes a problem arising from a condition that still exits. A late effect, on the other hand, is caused by a condition no longer in its acute phase," Bucknam says

Assign Late Effects as Secondary Diagnoses

When reporting late effects of an acute injury, your primary diagnosis should be the residual problem/condition. You should list the appropriate late effects code as a secondary diagnosis, according to section 1.7 of the Official ICD-9-CM Guidelines for Coding and Reporting.
 
For example, a patient injures his spinal cord in an auto accident. Some months later, the patient has pain and motor disturbance related to the previous injury and consults with the surgeon for treatment options. In this case, you should report the spinal cord injury (for example, 952.x, Spinal cord injury without evidence of spinal bone injury) first - even though the acute phase of the injury has passed - and the late effects (907.2, Late effect of spinal cord injury) as a secondary diagnosis, Bucknam says.
 
Reporting only the spinal cord injury denotes a new, acute injury. But by appending the late effects code, you indicate the presence of problems resulting from the previous injury, Bucknam says.
 
In a second example, a patient who was in an auto accident a year before presents to the office complaining of neck pain. Assuming that the physician can trace the neck pain to the earlier auto accident, you would report the primary symptom (847.0, Sprains and strains of other and unspecified parts of back; neck) followed by the appropriate late effects code (for instance, 905.8, Late effect of tendon injury). To add further specification, you should report the E code corresponding to late effects of a motor vehicle accident (E929.0).

Stroke Coding Follows Different Rules

Coding for CVA patients deviates from the general rule on coding late effects, says Julie Jarvis, CPC, owner of Underwood Billing, a coding and billing firm in Orlando, Fla. When reporting late effects of stroke, you need not report both the condition's cause and the residual effect. Rather, you should use a single ICD-9 code to describe late effects of CVA.
 
Codes describing late effects of stroke appear in a separate section (438) of the ICD-9 manual. These codes, such as 438.11 (Late effects of cerebrovascular disease; aphasia) and 438.21 (... hemiplegia affecting dominant side), describe both the residual condition and the cause.
 
If the surgeon sees a patient with late effects of stroke, you should report the late effect as the primary diagnosis. For example, a patient concerned about continued arm paralysis three months after a CVA consults with the surgeon. In this case, report 438.30 (... monoplegia of upper limb affecting unspecified side) as the primary diagnosis.
 
If, however, the physician admits the patient for treatment of another CVA, you should report the current CVA first, followed by any appropriate late effects code(s). This identifies those deficits that relate to the present CVA and those associated with pre-existing conditions. For example, the physician admits a patient having acute cerebral thrombosis. The patient previously had a stroke, which left her with impaired speech. Code the current condition first, using 434.0x (Cerebral thrombosis) and add 438.12 (... dysphasia) as a secondary diagnosis, Jarvis says. If the patient has no residual problems from the first CVA, you may report V12.59 (Personal history of certain other diseases of circulatory system; other) as the secondary diagnosis, according to Section 1.7 of ICD-9.

You Can Describe Unnamed CVA Conditions

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 (... 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.