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Know Your Sequencing for CVA Late Effects

Published on Fri Jan 20, 2012 Print Friendly and PDF PDF

Question: Our new patient was referred for care following a recent cerebrovascular accident (CVA) with hemiplegia of his dominant side, dysphagia, hypertension, gastroesophageal reflux disease (GERD), and diabetes. Both physical therapy and speech therapy will be seeing him to address the CVA residuals. Nursing will be seeing him for observation and assessment. How should we code for him?

Answer: List the following codes for this patient, says Trish Twombly, BSN, RN, HCS-D, CHCE, COS-C, HCS-O director of coding with Foundation Management Services in Denton, Texas:

  • M1020a: 438.21 (Late effects of cerebrovascular disease; hemiplegia affecting dominant side);
  • M1020b: 438.82 (Other late effects of cerebrovascular disease; dysphagia);
  • M1020c: 787.20 (Dysphagia, unspecified);
  • M1020d: 401.9 (Essential hypertension; unspecified)
  • M1020e: 530.81 (Esophageal reflux); and
  • M1020f: 250.00 (Diabetes mellitus without mention of complication; type II or unspecified type, not stated as uncontrolled).

Your inter-disciplinary focus of care for this patient is the late effects of his CVA, so you'll want to sequence these conditions first.

The general sequencing rule for late effects requires you to list two codes for each late effect. You would ordinarily list the condition or nature of the late effect first, followed by the late effect code.

But late effects of CVAs are an exception to the late effects coding guidelines. When coding for the late effects of a CVA, you'll often need only one code. Most late effects of stroke codes are combination codes, such as the one you will list to report your patient's hemiplegia -- 438.21, Twombly says.

Another exception: There are also some late effects combination codes that require additional information according to the coding guidelines. Some of the combination codes in the 438.xx category instruct you to add a second code. In those situations, you'll sequence your codes in reverse order than you would for other late effects: You'll code the late effect code first, followed by the residual.

So, if you were coding for the residual of a stroke and there is no ICD-9 combination code for your particular late effect, you would list 438.89 (Other late effects of cerebrovascular disease), Twombly says. You would follow this with a second code to identify the specific late effect.

In your scenario, when coding for your patient's dysphagia, you'll see a note to use an additional code to identify the type of dysphagia following code 438.82. So, for this patient you must also list 787.20.

Important: Many agencies miss out on case mix points because they don't understand the instructions at 438.82.

Next, list 401.9 for your patient's hypertension. As of Jan. 1, you no longer earn case mix points for this code, but it will impact the care you provide such as teaching on the disease process, possible medication side effects, which foods can increase blood pressure and signs and symptoms to look for indicating the blood pressure is not controlled, so it's still important to include, Twombly says. Follow this with 530.81 for the GERD.

Last, list 250.00 for your patient's diabetes. He doesn't have any diabetic manifestations, but this diagnosis will impact the care you provide.

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