Eli's Rehab Report

Question: One of our home health patients is a 79-year-old man who fell when he was getting out of his car on a slight incline, and the car rolled because it wasn't parked correctly. He hit his head and had a subdural hematoma that was surgically drained during his hospitalization. He is admitted for rehabilitation, with physical, occupational and speech therapy, with speech therapy expected to be in most often at first. Nursing will be doing some assessment and teaching. He has aphasia, blurred vision, left-side weakness (he is right handed) and tremor, and slurred speech. How should we code this patient?

Answer: Code this scenario as follows, 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:

• M1020a: V58.43 (Aftercare following surgery for injury and trauma);
• M1024: 852.20 (Subdural hemorrhage following injury without open intracranial wound, unspecified state of consciousness);
• M1022b: 784.3 (Aphasia);
• M1022c: 342.92 (Hemiplegia and hemiparesis unspecified, affecting non-dominant side); and
• M1022d: 368.8 (Blurred vision).

Your patient's hematoma was drained during surgery, so he no longer has a hematoma. Both nursing and therapy are seeing the patient, so it's appropriate to use an aftercare code as primary, in this case V58.43.

The subdural hemorrhage codes in the 852.xx category are Neuro 1 codes, so they qualify for inclusion in M1024 for additional case mix points. List 852.20 in M1024 across from your primary diagnosis code, V58.43.

Follow this with 784.3 to indicate your patient's aphasia co-morbidity. You won't list a separate code for slurred speech in this scenario because that symptom is considered part of aphasia.

The tremors your patient is experiencing may indicate spastic paralysis, so query the clinician about this possibility before choosing a hemiplegia code. If you can confirm the tremors are really spasms associated with the hemiplegia, list 342.12 (Hemiplegia and hemiparesis, spastic affecting non-dominant side). If not, then 342.92 is your code.

List 368.8 to report your patient's blurred vision. Finally, list 907.0 (Late effect of intracranial injury without skull fracture) to indicate that these conditions are the residuals of the intracranial injury.