Practice Management Alert

Expedite your MVA claims with late effects codes
 
If you don't know when and how to report late effects codes, you could be facing late payments or even denials. Test your billing savvy to ensure optimal payment.
 
Problem: Many coders report an acute condition, such as a fracture, when in reality the physician is treating the patient for a delayed effect of the acute condition, says Marvel Hammer, RN, CPC, CHCO, president of MJH Consulting in Denver. Take, for example, this billing scenario:
 
A trauma patient receives multiple injuries in a car accident, including a fractured femur (821.11, Fracture of shaft of femur, open). Several months after the physician removes the patient's cast, the patient continues to have pain and trouble walking on his injured leg. When he returns to the physician for treatment of his leg pain, a coder in the office reports 821.11 as the ICD-9 code for the visit. Consequently, the carrier denies this claim.
 
Solution: Determine how you would solve the billing problem above.

If you don't know when and how to report late effects codes, you could be facing late payments or even denials. Here's the answer to the late effects billing problem posed on the cover:

 Answer: The coder should have reported 729.5 (Pain in limb) as the primary ICD-9 code for the visit because the leg pain is the acute condition the physician was treating. As a secondary diagnosis, the coder should have reported 905.4 (Late effect of fracture of lower extremities) to indicate that the patient's past fracture is the cause of the current condition. To add further specification that would expedite the claim, the coder should have also added the E code for late effects of motor vehicle accident (E929.0).
 
Learn Late Effects and Reap the Benefits 

In general, late effects are the long-term effects of an injury or illness after the acute phase is over. Some late effects present early, while others might become apparent months or even years later. "There are no time limits for late effects," says Marcella Bucknam, CPC, CCS-P, CPC-H, CCA, HIM program coordinator at Clarkson College in Omaha, Neb.
 
Separate section: You can find all the late effects codes in a separate subsection of the ICD-9 manual (905-909), which describes "Late Effects of Injuries, Poisonings, Toxic Effects, and Other External Causes." You should also be familiar with the E929 code series for "Late Effects of Accidental Injury" - especially E929.0 for late effects of motor vehicle accident (MVA).
 
Watch out: But be careful not to confuse the late effects E codes with the E codes for current motor vehicle accidents (E810-819).

Use 4 Fail-Proof Tips

Here are four expert tips guaranteed to help your late effects coding:

1. Report late effects as secondary diagnosis. Late effects codes help you create the most specific and accurate picture of the patient's condition to justify medical necessity for either payment or authorization of services, Hammer says.
 
To paint a clear picture, you must report the reason for the patient's visit, such as leg pain, as the primary diagnosis. You must then report a late effects code, such as late effects of a fracture, as a secondary diagnosis to indicate the original acute condition causing the patient's current problem.
 
Expedite your claims: A major benefit of late effects codes is that  they can prevent a holdup when your claim reaches a motor vehicle accident or workers' compensation carrier, Hammer says. If the carrier already accepted a claim for treatment of the original injury, and then receives a claim months later for treatment of that same injury (with no late effects code), the carrier may suspend or deny payment until you verify that the patient doesn't really still have the same injury.
 
A claim with a late effects code, however, will show the carrier the medical necessity for the treatment, and your claim should get paid without delay. Similarly, you may prevent denials for lack of sufficient information by properly coding a patient's late effects.
 
2. Don't confuse late effects with complications: The two are not the same. A complication describes a problem arising from a condition that still exists. A late effect, on the other hand, is caused by a condition no longer in its acute phase, Bucknam says. Certain conditions, such as mal- or nonunion of fractures and scarring, are inherent late effects, regardless of when they occur.
 
3. Look for clues in the documentation. Certain words or phrases in the physician's documentation can help you identify a late effects visit. If the physician documents the patient has a condition "due to," "caused by" or "following" a previous condition, chances are the patient has late effects, Hammer says. Also, the words "late" and "old" should help tip you off to prior conditions.
 
4. Use only one code for strokes. Coding for patients with a cerebrovascular accident (CVA) is the exception to the late effects coding rule, Hammer says. You need only report one code from the 438 code series (Late effects of cerebrovascular disease) to indicate both the patient's present condition and the fact that a stroke caused the present condition, she adds.
 
For example, if a patient still has arm paralysis three months after a stroke, you should report 438.30 (... monoplegia of upper limb affecting unspecified side). For CVA patients, the late effects code serves as the primary diagnosis and you don't need a secondary code.