OASIS Alert

Mind these late effect coding quirks.

Home health coders can no longer list acute stroke codes. Make certain you read the notes to code for late effects of CVAs correctly or risk denied claims.

History: At one time, home health coders could report acute stroke codes when the patient was progressing with therapy and there had been no interruption in therapy during the patient’s transition from the hospital to home care.

Present day: In the 2008 revisions to the home health prospective payment system, acute stroke codes (430-437) became off limits for services provided in the home health setting. The Centers for Medicare & Medicaid Services removed these codes from the case mix list, and directed home health coders to the 438.xx (Late effects of cerebrovascular disease) codes for their stroke patients with late effects. The 438.xx codes are now PPS case mix codes under the Neuro 3, Stroke category.

Off limits: At one time, 436 (Acute but ill-defined cerebrovascular disease) was the go-to code for unspecified strokes. But this code no longer indicates stroke or CVA.

Know 2 Late Effects Exceptions for CVAs

Ordinarily, when coding for a late effect in M1020 or M1022, you’ll list two codes. You’ll sequence the presenting problem first, followed by the late effect code. But CVA late effects are a different story.

Exception 1: Combination Codes

When coding for the late effects of a CVA, you’ll often need to list only one code, says Sharon Molinari, RN, HCS-D, COS-C, a home health consultant based in Henderson, Nev. Several codes in the 438.x (Late effects of cerebrovascular disease) category are combination codes that include both the presenting problem with the late effect in one code, she says.

For example: 438.12 (Late effect cerebrovascular disease; dysphasia).

Exception 2: Reverse Sequencing

Not all of the CVA late effects combination codes completely describe the patient’s condition. Some of them require an additional code to accurately report the diagnosis. Look for a “Use additional code” note to see when you need to add a second code, Molinari says.

Reverse thinking: When you are instructed to include an additional code to identify your patient’s CVA late effect, you’ll reverse the sequence as compared to other late effects. With CVA late effects requiring two codes, you’ll list the late effect code first, followed by the residual or presenting problem.

Background: The Official ICD-9-CM Guidelines for Coding and Reporting instruct you to list a secondary code when a “combination code lacks necessary specificity” to describe a manifestation or complication. That means that you should add the code that provides more specificity about the nature of the residual, says Lisa Selman-Holman, JD, BSN, RN, HCS-D, COS-C, consultant and principal of Selman-Holman & Associates and CoDR — Coding Done Right in Denton, Texas.

For example: Suppose your patient was admitted to home health for physical therapy and occupational therapy due to ataxia and double vision related to a transient ischemic attack (TIA). There is no nursing ordered. You would list the following codes for this patient:

• M1020a: V57.89 (Multiple training or therapy);
• M1022b: 438.84 (Other late effects of cerebrovascular disease; ataxia);
• M1022c: 438.7 (Late effects of cerebrovascular disease; disturbances of vision);
• M1022d: 368.2 (Diplopia).

Your primary diagnosis for this patient is V57.89, because two different therapy disciplines will be providing care in this therapy-only scenario. You’ll also need to list two different late effect codes for this patient.

The first, 438.84, is a combination code describing both the etiology of the patient’s condition (CVA) and the residual (ataxia).

With 438.7, for the patient’s visual disturbance, you’ll find a note instructing you to list an additional code to describe the vision disturbance. So, you’ll need to list the late effect code (438.7) first, followed by 368.2 for the diplopia.

Another example: What if you’re coding for the residual of a stroke and there’s no ICD-9 combination code to describe the condition? In this situation, list 438.89 (Other late effects of cerebrovascular disease), followed by a second code to identify the specific late effect. So, if your patient has generalized muscle weakness as the late effect of a stroke — and not a more specific condition like monoplegia (438.4x) or hemiplegia (438.2x), you would list 438.89 and then 728.87 (Muscle weakness [generalized]).