Wiki Status Post CVA at 10 months

[Alicia Scott]

I need some help as this is not my forte. This is a 16 yr old femal pt.
Assessment per PCP visit note:
1. Status post CVA at 10 months with rt hemiparesis and lft facial droop
2. Expressive aphasia
3. Tension and migraine headaches
4. Heavy periods that are irregular and painful
5. Learning disability due to inability to focus
6. Substantial loss of function and power in both rt uper and lower extremities secondary to CVA
7. Tension and/or mirgraine headaches related to CVA that occured when she was a child
8. Radical deviation of her rt hand with total absence of sensation of both upper and lower extremities with the exception of the sole of her foot

The cause of the CVA was undetermined. My question is what falls under the late effect of the CVA and what doesn't? The visit was done to determine if the patient is qualified for Social Security and Medicaid.

I appreciate your help.

 

[dadhich.girish]

Per official ICD-9-CM guidelines:

A late effect is the residual effect (condition produced) after the acute
phase of an illness or injury has terminated. There is no time limit
on when a late effect code can be used. The residual may be apparent
early, such as in cerebrovascular accident cases, or it may occur
months or years later, such as that due to a previous injury.


Whenever the acute phase of a disease is treated and there are no symptoms whatsoever and after that period, if there is any symptom occuring, it should be coded as late effects of that disease.

HTH.

 

[Alicia Scott]

Thank you

This was helpful. I appreciate the information.