Coding Late Effects of Cerebrovascular Disease
Category 438 is used to identify residuals or late effects of cerebrovascular disease when a patient is seen or admitted at a later date. These late effects include neurological deficits that persist after the initial onset of the cerebrovascular event.
For example: A patient is seen with hemiplegia on the dominant side due to an old CVA. Code 438.21, Late effects of cerebrovascular disease, hemiplegia affecting dominant side is assigned.
Codes from category 438 may be assigned as the principal diagnosis when the reason for admission is to deal with the late effect. However, if the admission is for rehabilitation a code from category V57, Care involving use of rehabilitation procedures is assigned as the principal diagnosis with an additional code from category 438.
For example: A patient is admitted for rehabilitation consisting of speech therapy, occupational therapy and physical therapy for residual aphasia and hemiplegia following a CVA. In this instance code V57.89, Other specified rehabilitation procedure, is assigned as the principal diagnosis. Codes 438.11, Late effects of cerebrovascular disease, Aphasia, and 438.20, Late effects of cerebrovascular disease, Hemiplegia affecting unspecified side are assigned as additional diagnoses.
Codes from category 438 may also be assigned as additional diagnoses when a patient is admitted with a new CVA and residuals from a previous episode remain at the conclusion of the visit.
When appropriate, a code from category V12.59, Personal history of other diseases of circulatory system may be used when a patient has a prior CVA but has no residual conditions. Personal history codes explain a patient's past medical condition that no longer exists and is not receiving any treatment. A history of an illness, even if no longer present, is important information that may affect the type of treatment ordered.
In some cases, the neurologic deficits diminish or disappear within weeks or months of the CVA, while in others the neurologic deficits persist. The degree of impairment varies from case to case.
For example: A patient is admitted for routine cataract extraction and the history and physical examination indicates weakness of the left arm. The physician documents old CVA as a secondary diagnosis. There is no other supporting documentation regarding this diagnosis. In this instance, query the physician to determine the source of the left arm weakness because the physician did not state that the weakness was the result of the old CVA. If the physician documents that the arm weakness is not due to the old CVA, assign code V12.59, Personal history of other diseases of the circulatory system, for the history of old CVA.
Take the following quiz to test your knowledge of coding cerebrovascular diseases.
1. After hospitalization for an acute stroke, a patient is transferred to a nursing home. She has received a gastrostomy in the hospital and care will be provided for it at the nursing home. However, the primary reason for her transfer to a nursing home is left hemiplegia and dysphasia from the stroke. What are the appropriate diagnosis codes and how would they be sequenced?
a. V55.1, 438.20, 438.12
b. 438.20, 438.12, V55.1
c. 434.91, 342.90, 784.5, V55.1
d. 434.90, 342.90, 784.5, V55.1
2. A patient is admitted through the ED with a diagnosis of CVA. CT scan of the brain showed a thombotic infarction of the brain. The patient has a history of hypertension and is continued on meds. The patient experienced residuals of hemiplegia and aphasia but they were not present at the time of discharge. Which of the following is the correct code assignment?
a. 436, 401.9
b. 434.01, 401.9
c. 434.00, 401.9
d. 434.01, 342.90, 784.3, 401.9
3. A patient is admitted with occlusion of the cerebral arteries resulting in an infarction. The patient suffered a stroke 1 year ago with residual hemiplegia affecting her dominant side. What would be the correct code assignment?
a. 434.91, 438.21
b. 434.91, V12.59
d. 436, 438.21
4. A patient is admitted after being found unresponsive at home. The physical examination reveals right-sided hemiplegia and aphasia that does not resolve by discharge. The physician documents CVA as the final diagnosis and the patient is transferred for rehabilitations. What would be the correct code assignment?
b. 436, 432.90, 784.3
c. 434.91, 432.90, 784.3
d. 434.90, 432.90, 784.3
This month's column has been prepared by Cheryl D'Amato, RHIT, CCS, director of HIM, and Melinda Stegman, MBA, CCS, manager of clinical HIM services, HSS Inc. (www.hssweb.com), which specializes in the development and use of software and e-commerce solutions for managing coding, reimbursement, compliance and denial management in the health care marketplace.
Answers to CCS Prep!:
1. b. Code 438.20, Late effects of cerebrovascular disease, Hemiplegia affecting unspecified side, and code 438.12, Late effects of cerebrovascular disease Dyspha-sia, should be the first listed codes. Code V55.1, Attention to artificial openings, gastrostomy, may be listed as a secondary diagnosis. The acute CVA should not be coded because the initial treatment of the CVA is completed.
2. b. 434.01 is assigned as the principal diagnosis because a cerebral thrombosis is documented. The fifth digit of 1 is assigned to show the infarction. The hypertension code, 401.9, should also be assigned because the patient is on medication for the condition. The hemiplegia and aphasia are resolved by discharge, so they are not coded.
3. a. 434.91 is assigned as the principal diagnosis to identify the occlusion of the cerebral arteries with infarction. 438.21 is assigned to identify the residual hemiplegia resulting from a previous stroke. Residual conditions from a previous condition may be reported with another acute infarction. V12.59 is not reported because there are residual conditions from a previous stroke.
4. c. 434.91 is assigned as the principal diagnosis to identify the CVA. 436 is no longer the default CVA code. The fifth digit of 1 is assigned because CVA not otherwise specified will now always be coded as with infarction. Code 432.90 and 784.3 are used to identify the residual neurological defects hemiplegia and aphasia.