Eli's Rehab Report

Question: For a late effect CVA (cerebrovascular accident), or stroke, patient, should I assign the fifth digit of hemiplegia (438.2x) to the dominant/ nondominant side of the brain or the dominant/ nondominant side of the body?

Rhode Island Subscriber

Answer: The basic definition of hemiplegia/ hemiparesis (438.2x) is "paralysis affecting one side of the body." You should therefore assess which side of the body is dominant or nondominant and code accordingly: 438.20 (Late effects of cerebrovascular disease; hemiplegia affecting unspecified side), ICD-9 438.21 (... hemiplegia affecting dominant side) or 438.22 (... hemiplegia affecting nondominant side). For example, if a patient is right-handed and the stroke paralyzes her right side, then you would select 438.21.

Remember: CVApatients are the exception to the general rule regarding coding late effects. Normally you would use two codes -- one for the residual effect and a second for the cause of the condition. CVAcodes, however, include both the residual effect and cause. Therefore, you should assign just one code when the late effects code includes a fourth or fifth digit describing the residual condition.

If your physician simply discharges a patient from the hospital after treating her for a stroke, you need not report a late effects code. Instead, you should use the correct code from the 430-437 series (Cerebrovascular disease) to describe the CVA(e.g., 434.0x) and use the ICD-9 codes that denote the impairments that the patient still has. For example, if such a patient has paralysis on her nondominant side, report the secondary diagnosis code 342.92 (Hemiplegia; affecting nondominant side).