Eli's Rehab Report

Question: Our 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. How should we code for him?

Answer: Code for this scenario as follows, says Trish Twombly, BSN, RN, HCS-D, CHCE, COS-C, HCS-O, director of coding with Foundation Management Services in Denton, Texas.

• 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);
• M1022d: 368.2 (Diplopia).

When coding for a patient who has had a cerebrovascular accident (CVA) or TIA in home health, you can't list an acute stroke, Twombly says.

In these situations, if your patient had no residuals, you would use a V-code to describe the care you provide, Twombly says. But if your patient has residuals from a CVA/TIA, you will code for it as a late effect of CVD.

Why? The 435 series acute TIA codes are reserved for acute care settings and should be coded as a late effect CVD according to the tabular instructions.

Take note: The 438 codes are not actually late effect CVA codes, but late effects of cerebrovascular disease, including TIAs, 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.

Your primary diagnosis for this patient is V57.89. This is a therapy-only situation, but two therapy disciplines will be seeing this patient, so you'll want to use the multiple therapies code, Twombly says. Remember, in home health the V57.x codes can only be listed as primary.

You'll need to list two different late effects codes for this patient. The first, 438.84, is a combination code, Twombly says. Both the CVA and the ataxia are in the code title, so you only need to list one code and you don't need to worry about sequencing for this diagnosis. Both the underlying etiology and the residual are included in this combination code.

Sometimes combination codes require additional information. This is the case with 438.7. So you'll need to consider "use additional code" conventions when you code for the patient's diplopia.

In this situation, you need to list the late effect code (438.7) first. You'll find a note following 438.7 in your coding manual which instructs you to use an additional code to describe the vision disturbance, Twombly says. So, you must list 368.2 immediately following the 438.7 code.