Wiki kjohnsonmedrehab

[phlebokim]

Good Morning,
I have an ongoing discussion within our facility regarding the correct code for weakness or hemiplegia following a CVA. Can we apply a 438.20 for a patient's diagnosis, if the only defficit is weakness and not paralysis as described in the Physicians H&P? Or should the code be 780.79 when no hemiplegia description is provided?
I hope that the reason no one has responded is due to my not providing enough informatio. This coding question is for an inpatient at a rehabilitation hospital. If anyone has an answer for me, I would be ever so grateful.

 

[mhstrauss]

IMO, use 438.89-Other late effects of CV disease, which requires use of additonal code-780.79- to identify the late effect. Hope this helps!!

 

[phlebokim]

Thank you so much. I was pretty sure that was the correct steps, but as a fairly new coder, It is good to have someone help assure you that you are doing it correctly! Thanks again.