Eli's Rehab Report

Tip: Check first whether only one or two different therapy disciplines are at work.

If you have kept track of how changes for coding for strokes or cerebrovascular accidents (CVA) in home health have affected documentation requirements, then you know that you have more than one option to report the progress of your stroke patients.

History: At one time, home health coders were permitted to 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: When the home health prospective payment system was revised in 2008, acute stroke codes (430-437) were designated as no longer appropriate for services provided in the home health setting. The Centers for Medicare & Medicaid Services (CMS) 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, 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 sequence your codes in reverse order than you would normally for 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); and
• 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 effect (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 the more specific condition monoplegia (438.4x) or hemiplegia (438.2x), you would list 438.89 and then 728.87 (Muscle weakness [generalized]).