Eli's Rehab Report

Warning: This isn't your free-and-clear ticket to stroke coding. Get specific

When your physiatrist writes down "stroke" as the patient's diagnosis, you can automatically record ICD-9 code 434.91, thanks to a change in the 2005 ICD-9 Alphabetic Index - but you still need to be careful using this code. According to our experts, there are more precise diagnosis codes that are a better fit (and more accurate) when coding this condition.

Make the Transition

In the past, for a simple diagnosis of "stroke," the ICD-9 Index listed 436 (Acute, but ill-defined, cerebrovascular disease) as the appropriate code, says Jackie Miller, RHIA, CPC, senior consultant at Coding Strategies Inc. in Dallas, Ga.
 
Now the Index lists 434.91 (Cerebral artery occlusion, unspecified, with cerebral infarction) as the code you should report. Under the new ICD-9 Alphabetic Index, a diagnosis of "cerebrovascular accident" or CVA will also automatically translate to an occlusion with infarction, Miller says.

Act now: Some coders haven't yet caught up with the change from 436 to 434.91 for stroke, and some practices haven't adjusted their preprinted superbills or coding reference sheets to reflect the new rule, Miller says. The reason may be that this change did not incorporate new diagnoses or delete existing codes - it just adjusted the "pointer" in the alphabetic index.

Even though this change seems minor, it will allow for reimbursement on some previously noncovered services for stroke patients. "There have been some scenarios in the past where [providers] might not get paid for an interpretation of a CT or an MR" scan with a diagnosis of 436, but they would with 434.91, Miller says.
 
Keep in mind: You may not find any specific benefits for your physical medicine and rehab practice, but the advantage lies with better data collection, especially with regard to potential tracking of "best practices" treatment efficacy.
 
Don't Stop Documenting Details

This change has made coders' lives easier but may also make coders less persistent about encouraging doctors to document more precise diagnoses, says Sandy Nicholson, a consultant with Pershing Yoakley & Associates in Atlanta. Now physiatrists can get away with writing down "stroke" without going into more detail - and that means you could be missing out on specific diagnoses that justify the procedures the physician performed.

For example, if the patient has a stroke with cerebral hemorrhage and the physiatrist fails to note this complication, it could vastly understate the seriousness of the patient's condition, Nicholson says. "Embolic strokes have one-fifth the mortality rate of hemorrhagic strokes," she says. Also, if other providers don't realize the patient has a hemorrhage and they start him on Coumadin or aspirin, the patient could experience potentially fatal side effects.

If the physiatrist specifies that the patient has a hemorrhage, the coder would use ICD-9 code 431, Miller says. Medicare will cover some procedures for a stroke with hemorrhage but not without, such as surgical or transcatheter interventions. "The more specific [providers] can be, the better off they're going to be," Miller says.

Don't overlook late effects: Physiatrists frequently take care of patients who have had a stroke and manage the sequelae of the "stroke." If your provider sees a patient under this circumstance, you should use the 438.xx late effects range, rather than the acute stroke code.