Neurology & Pain Management Coding Alert

Turn to the 438.xx series if the neurologist is managing late effects of stroke You may think you should report 434.91 for stroke, but according to our experts, there may be more precise diagnosis codes that fit better when coding this condition. Avoid 436 for Stroke Prior to 2005, for a simple diagnosis of "stroke," you would have reported 436 (Acute, but ill-defined, cerebrovascular disease) as the appropriate code, says Jackie Miller, RHIA, CPC, senior consultant at Coding Strategies Inc. in Dallas, Ga.

Now, the ICD-9 index lists 434.91 (Cerebral artery occlusion, unspecified, with cerebral infarction) as the appropriate diagnosis for stroke. Under the new ICD-9 Alphabetic Index, a diagnosis of "cerebrovascular accident," or CVA, will also automatically translate to an occlusion with infarction, Miller says.

Act now: Some coders haven't yet caught up with the change from 436 to 434.91 for stroke, and some practices haven't adjusted their preprinted superbills or coding reference sheets to reflect the new rule, Miller says. The reason may be that this change did not incorporate new diagnoses or delete existing codes - it just adjusted the "pointer" in the alphabetic index.

Even though the transition to 434.91 seems minor, the new diagnosis will allow for reimbursement on some previously noncovered services for stroke patients. "There have been some scenarios in the past where [providers] might not get paid for an interpretation of a CT or an MR" scan with a diagnosis of 436, but they would with 434.91, Miller says.

Keep in mind: You may not find specific benefits for your practice, but the advantage lies with better data collection, especially with regard to potential tracking of "best practices" treatment efficacy. Don't Stop Documenting Details The improved coding for stroke has made coders' lives easier but may also make coders less persistent about encouraging doctors to document more precise diagnoses, says Sandy Nicholson, a consultant with Pershing Yoakley & Associates in Atlanta. Now neurologists can get away with writing down "stroke" without going into more detail - and that means you could be missing out on specific diagnoses that justify the procedures the physician performed.

For example: The neurologist's failure to note a complication of cerebral hemorrhage with stroke could vastly understate the seriousness of the patient's condition, Nicholson says. "Embolic strokes have one-fifth the mortality rate of hemorrhagic strokes," she says.

Also, if other providers don't realize the patient has a hemorrhage and they start him on Coumadin or aspirin, the patient could experience potentially fatal side effects.

If the neurologist specifies that the patient has a hemorrhage, you should use ICD-9 code 431, Miller says.

Medicare will cover some procedures for a stroke with hemorrhage but not without, such as surgical or transcatheter interventions. "The more specific [providers] [...]