Eli's Rehab Report

Make the most of multiple code choices.

It’s time to get up to speed on ICD-10 coding. While some diagnoses won’t have many changes in ICD-10 compared to ICD-9, the sequelae (or late effects) of cerebrovascular accidents (CVAs) codes offer more choices and specificity than you currently have. 

Know When One Code is Not Enough

Category I69 (Sequelae of cerebrovascular disease) has a variety of combination codes that may allow you to specify your patient’s condition. Presently, in ICD-9-CM, we report 438 (Late effects of cerebrovascular disease) for the situation. However, there will still be situations when a single code would not suffice. You may need to use additional codes in such situations where one code doesn’t quite do the job.

What’s new in dominance: ICD-10 lets you report whether the condition impacts the dominant or non-dominant side. This comes in handy and is very important in neurological conditions such as hemiplegia, hemiparesis, and monoplegia.

When the documentation indicates the affected side, but doesn’t tell you whether it’s the patient’s dominant or non-dominant side, base your choice on the following guidance:

• For ambidextrous patients, the default choice is dominant.

• If the left side is affected, the default choice is non-dominant.

• If the right side is affected, the default choice is dominant.

Example: A patient was admitted following a CVA. He has right-sided hemiplegia and dysphagia (or difficulty in swallowing) as a result of the CVA.

Here is a list of the codes that apply for this patient:

• I69.351 (Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side);

• I69.391 (Dysphagia following cerebral infarction);

• R13.10 (Dysphagia, unspecified).

You know that patient has right-sided hemiplegia, but do not have any documentation regarding dominance. According to the guideline, since the patient’s right side is affected, the default is to report this as affecting his dominant side.

When you locate I69.391 in the tabular list, you’ll find a note asking you to “Use additional code to identify the type of dysphagia, if known (R13.1-).” You don’t have any additional details about the phase of your patient’s dysphagia, so R13.10 for “unspecified” is your correct code choice.