OASIS Alert

Think you've got CVA figured out? Late effect turns guidelines upside down.

When coding for late effects, any mistakes could create an inaccurate record, reimbursement delays, and payer headaches.

But you can avoid those hassles if you keep this in mind: Sequencing is everything. Ourexperts offer one rule of thumb and two exceptions to ensure you're accurate every time.

A late effect is the condition produced after the acute phase of an illness or injury has run its course, according to the ICD-9-CM Official Guidelines for Coding and Reporting.

There is no time limit on when you can report a late effect, according to the guidelines. The residual effect of your patient's illness or injury may be apparent early, such as when he's had a cerebrovascular accident (CVA). Or a residual may occur months or years later, such as when your patient has had a previous injury.

Dig deeper: Frequently the original illness or injury is forgotten, says Jan McLain, with Adventist Health System Home Care in Port Charlotte, Fla. Identifying a true late effect can require investigation of the past medical history and targeted questioning to determine the relationship between the event from years before to the symptoms that are presenting today.

Narrow your search: Many coders aren't sure how to find the code they need to indicate the residual effect of a disease or injury. "They'll look under 'syndrome' or 'complication' in the alphabetic index of the coding manual," says Trish Twombly, director of coding with Foundation Management Services in Denton, Texas. And there's no section in the tabular list of  your coding manual that includes all the late effects codes, Twombly notes.

To find the right late effect code, look in the alphabetic index under "late effects." Then look through the sub-terms to find the diagnosis that fits your patient.

For example: Your patient has myelitis as a late effect of polio. When you get to the subterm "Polio" in the alphabetic index, it says "(Conditions classifiable to 045) 138." You would use 045.xx (Acute poliomyelitis) for your patient if he had polio today, says Twombly.Check the code series the late effect code references to make sure you have found the right code for your patient.

Insider tip: Never use the code for the acute phase of an illness or injury that led to the late effect in conjunction with a code for the late effect.

You'll generally need to list two codes for a late effect -- let this guide your late effects coding. Sequence the condition or nature of the late effect first, followed by the late effect code.

For example: Your patient had polio as a child. Now you are providing care for the late effect of paraplegia. To code for this patient,Twombly says you would list the following:

• 344.1 -- Paraplegia

• 138 -- Late effects of acute poliomyelitis.

Case mix: Paraplegia is a Neuro 1 case mix code and polio is one of the few late effect etiologies that can earn case mix points.

CVAs are the first exception to late effects coding guidelines. When coding for the late effects of a CVA, you'll often need only one code. Most late effects of stroke codes are combination codes, Twombly says.

For example: Two new late effects of stroke codes became available Oct. 1, 2009:

• 438.13 -- Late effects of cerebrovascular disease; dysarthria and

• 438.14 -- Late effects of cerebrovascular disease; fluency disorder.

There are some combination codes,however, that still require additional information according to the coding guidelines. Some of the combination codes in the 438.xx category instruct you to add a second code. In those situations, you will sequence your codes in reverse order than you would for other late effects: You'll code the late effect code first, followed by the residual, says Lisa Selman-Holman, consultant and principal of Selman-Holman & Associates and CoDR -- Coding Done Right in Denton, Texas.

So, if you're coding for the residual of a stroke and there is no ICD-9 combination code for it you would list 438.89 (Other late effects of cerebrovascular disease), Twombly says. Follow this with a second code to identify the specific late effect.

For example: Your patient has generalized muscle weakness -- not the more specific condition monoplegia (438.4x) or hemiplegia (438.2x). You would list 438.89 and then 728.87 (Muscle weakness [generalized]).

Another example: When coding for dysphagia as a late effect of stroke, you're required to list an additional code to describe the dysphagia type along with the combination code 438.82 (Other late effects of cerebrovascular disease; dysphagia). In home care, you often won't have this detailed information, so you will list 787.20 (Dysphagia, unspecified).

Many agencies miss out on case mix points because they don't understand the instructions at 438.82.

Manifestations are the second exception in late effect coding. When the condition produced from the late effect you're coding for is designated as a manifestation code, you'll need to follow manifestation coding guidelines.

Manifestation coding rules trump other rules, Twombly says. When coding for manifestations, you must sequence the underlying etiology first, followed by the manifestation code.

For example: Your patient has curvature of the spine as a late effect of polio. For this patient, Twombly suggests coding 138 for a late effect of polio first, followed by 737.40 (Curvature of spine, associated with other conditions; unspecified).