Wiki Cva

[tallarico_michelle@yahoo.com]

I am coding a patient that came into the office to get rechecked for a fall. The reason the pt fell was due to slipping. In the final diagnosis md states pt has a closed head injury subsequent encounter along with a skin tear due to the fall.d also states he of cva along with stroke. Dr documents the stroke is due to embolism of cerebral artery. Would I code this as 163.40 or would I code this as a hx? Also the dr states pt has confusion, fall . I coded the injury code with W19.xxxd for fall. Would you also code repeated falls and history of falling with the W code? If someone can please direct me into the correct direction to code along with the guidelines thank you!

 

[Pam Warren]

Code the confusion, the lac, the closed head injury (not the same thing), along with the fall, subsequent encounter.
Code also a History of CVA, but don't link it to the confusion as a late effect unless the provider specifically does (or query him). Unless the provider comes right out and says that the fall is because of confusion and the confusion is a late effect of the stroke, you code history of, not late effect. We can never assume.

Never code an acute stroke unless the patient is stroking right in your office.

It might be helpful for you to spend some additional time in the current ICD-10-CM book to re-review the coding standards and principles--the front of the book as well as each section. Every question you have here is explained in the book.

 

[tallarico_michelle@yahoo.com]

The only reason why I was questioning this , is my lead told me to code repeated falls, bc of fall and an injury fall code along with a bc of cva. I didn’t code the encounter the way my lead told me, I was just making sure it wasn’t coding this encounter incorrectly. Just wanted some advice on the correct way.