A home health agency receives a referral from the hospital for a patient who had a cerebrovascular accident (CVA). Patient has right-sided weakness as a residual from the CVA. Referral requested skilled nursing services, along with physical therapy services. Patient was discharged to home Tuesday. A clinician admitted patient to home health services the same day. A physical therapist also visited the patient to do a therapy evaluation. The coder receives the patient's chart for coding Wednesday.
In reviewing the data in the chart, the coder learns patient had a CVA and has right-sided weakness, but the documentation does not state if this is the patient's dominant side. When you look up CVA in the alpha index, you see cerebrovascular (current) (CVA) (see also Disease, cerebrovascular, acute) 434.91. When you go to the code 434.91 in the tabular section of the coding book, you find 434.9 cerebral artery occlusion, unspecified and there's an indication this code needs a fifth digit. The choices are 0 - without mention of cerebral infarction and 1- with cerebral infarction. However, directly under this there is a coding tip that tells you the 434 codes are for the acute setting only and they are not to be used in home health. You may use the 434 code in answering the OASIS questions asking why the patient was in the hospital and what changes have occurred with this patient's health in the last 14 days. The coding book instructs you to look at codes starting with 438 for residuals of the CVA.
When you go to 438 late effects of cerebrovascular disease, you look for the 438 code that shows the residual of right-sided weakness. The coding book states as a coding tip, that Hemi paresis is weakness of one side of the body. This is often documented as "left-sided weakness" of "right-sided weakness." In looking at the available codes to choose from, you may select hemiplegia, affecting unspecified side, hemiplegia affecting dominant side and hemiplegia affecting nondominant side. The hospital documentation did not state whether it was the dominant or nondominant side. You could choose to code the unspecified code, but it's best to be as specific as possible, so you check the assessment to see if the clinician documented in the assessment which side is affected. If the documentation is not in the assessment, the coder should call the physician's office to clarify which side is affected.
For this patient, the dominant side is the side that is affected per the clinician's documentation. So you code 438.21. This code supports the skilled nursing services and the physical therapy services.
When reading the hospital's history and physical, it states the patient has past medical history of hypertension and stage 2 chronic kidney disease. These are important co-morbidities you want to show in coding for this patient.
Hypertension is in the form of a table in the coding book. When you go to the table in the alpha index, you see with chronic kidney disease 403.90. Report hypertensive chronic kidney disease whether it's stated as a relationship in the documentation or not. You can assume the relationship between hypertension and chronic kidney disease. In looking in the tabular section for 403.90 hypertensive chronic kidney disease, the coding book indicates this also needs a fifth digit. The options are 0 -with chronic kidney disease stage I through stage IV, or unspecified. Use additional code to identify the stage of chronic kidney disease (585.1 - 585.4, 585.9) or 1 -with chronic kidney disease stage V or end stage renal disease. Use additional code to identify the stage of chronic kidney disease (5855, 585.6).
You then need to look for the additional code to report the stage 2 chronic kidney disease. When you go to the 585 codes, it tells you to code the hypertension followed by the chronic kidney disease. Stage 2 chronic kidney disease is 585.2.
This would be coded as:
Primary diagnosis 438.21 Late effects of cerebrovascular disease
with hemiplegia affecting dominant side
Secondary diagnosis 403.90 Hypertensive chronic kidney disease
585.2 Chronic kidney disease - stage II
You document the 438.21 late effects of cerebrovascular disease with hemiplegia as primary because that it what the clinician stated as the focus of care for this patient.
Jen Noel has worked in the home health industry for more than 16 years with the Visiting Nurse Association of Hanover and Spring Grove, learning many aspects of home health and completing many job responsibilities. She started learning coding approximately 4 years ago through a co-worker, workshops and becoming a member of a coding forum. She became a certified home health coding specialist - diagnosis (HCS-D) on Nov. 1, 2007 and is now working for Parente Randolph as a consultant in addition to her work with the Visiting Nurse Association of Hanover & Spring Grove on a PRN basis.