Wiki Coding Help for Rehabilitation Hospital Inpatient

[phlebokim]

Hello,
I am uncertain as to how I should code a patient's deficits, when both a current fall and a past CVA are present on admission. Can the hemiparesis be coded as 342.90 or should this be 438.20? I am confused as to when the late effects of the CVA should be coded, or if I should be coding these deficits to the new diagnosis of the fall.

 

[mitchellde]

When the reason for the admission is rehab then your first listed dx code is the appropriate V57.x code followed by the reason for rehab, as to whether that is a late effect of the CVA will depend on the
documentation.

 

[phlebokim]

Example. Patient presents with a fall, deficits are right fx humerus, periorbital hematoma. Physician documents unable to elicit voluntary movement of right arm. Patient can move areas of the right hip and knee, and all areas of left side. Patient does have right facial droop, is apraxic, and ataxic. Patient also has had a previous CVA. What hemiparesis code should I be using 342.90 or 438.20?