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Eli's Rehab Report

How to Improve Late Effects Coding

Published on Mon Nov 15, 2004 Print Friendly and PDF PDF

5 strategies keep complications out and reimbursement in

Overlooking late effects ICD-9 codes could mean submitting inaccurate information and possibly compromising physician reimbursement. Fortunately, recognizing late effects can be simple when you use the following five easy strategies.
 
1. No Time Limits for Late Effects

Late effects are the long-term effects of an injury or illness after the acute phase is over. For example, a patient may have a vertebral fracture and continue to have pain years after the fracture heals. Some late effects present early, while others might only become apparent months or years later. "There are no time limits for late effects," says Linda Becker, RN, CMC, physician office manager at Madonna Rehabilitation Hospital in Lincoln, Neb.

The ICD-9 manual provides a separate subsection (905-909) describing "late effects of injuries, poisonings, toxic effects, and other external causes." Late effects that physiatrists commonly see include 905.0-905.9 (Late effect of musculoskeletal and connective tissue injuries), 907.0-907.9 (Late effects of injuries to the nervous system) or 908.6 (Late effect of certain complications of trauma), for example.

Late effects tell the whole story of a patient's condition, and they present a much clearer picture to the carrier of why a physician may choose to treat a patient in a particular way, says Terry Fletcher, BS, CPC, CCS-P, CCS, CMSCS, CMC, a coding and reimbursement specialist in Laguna Niguel, Calif. Specifically, late effects codes link what is going on with the patient now with what happened in the past. "Like E codes for external causes of injury and poisoning, late effects codes provide a more complete picture of the reason for treatment and can become an issue for patients who are injured in an auto accident or in workers' compensation claims," Fletcher says.

As rehabilitation coders, you'll find that you will use late effects codes more than other specialties. "Our outpatient clinic sees patients with residual problems from spinal cord injuries, traumatic brain injuries, orthopedic injuries as well as conditions such as cerebral vascular accident (CVA)," Becker says. "We use a wide range of late effects codes daily."

"We often use codes for late effects of cerebrovascular disease (438.0-438.9)," adds Babette Christofferson, coding and billing specialist at Scottsbluff Physiatry Associates in Scottsbluff, Neb.

2. Use Keywords to Detect Late Effect

To determine if a condition is a late effect, you should look for keywords in the physician's documentation. According to Becker, such keywords might include:

  • due to - such as "pain in right hip due to fracture last year"

  • following - such as "personality changes following a brain injury in 1996"

  • as a result of - such as "hemiplegia as a result of CVA"

  • residual effect - such as "arthritis that is a residual effect of previous hip fracture."

    Heads-up: Don't confuse late effects with complications. "A complication is essentially not a part of a patient's disease, condition or problem," Christofferson says. A complication is typically associated with a difficulty or problem that occurs with a specific procedure (996.xx) and not the sequelae due to the original disease or injury.

    3. Assign Secondary Diagnoses

    When you report late effects of an acute injury, your primary diagnosis should be the residual problem/
    condition. You should list the appropriate late effects code as a secondary diagnosis, according to section 1.B.12 of the Official ICD-9-CM Guidelines for Coding and Reporting.

    For example: A patient fractures his tibia in a fall. Several months later, the patient develops numbness in the foot and continues to have pain in the knee. She consults with the physiatrist for testing and treatment. The PM&R physician's documentation indicates that these symptoms are due to the past tibia injury. 

    In this case, you should first report the knee joint pain (719.46, Pain in joint, lower leg) and numbness (782.0 Disturbance of skin sensation) and then code the late effect (905.4, Late effect of fracture of lower extremities).

    4. Follow Other Rules for Stroke Coding

    Coding for CVA patients deviates from the general rule on coding late effects. When reporting late effects of a stroke, you need not report both the condition's cause and the residual effect. Rather, you should use a single ICD-9 code to describe CVA late effects. "There are codes specifically assigned to the most common late effects of CVA," Becker says. 

    Codes describing late effects of stroke appear in a separate section of the ICD-9 manual (438). These codes, such as 438.11 (Late effects of cerebrovascular disease; aphasia) and 438.21 (... hemiplegia affecting dominant side), describe both the residual condition and the cause of the condition.

    Example 1: A patient is concerned about continued arm paralysis three months after a CVA and consults with your physiatrist. You should report the late effect as the primary diagnosis. Therefore, you should report 438.30 (... monoplegia of upper limb affecting unspecified side) as the primary diagnosis.

    Example 2: However, if the physician admits the patient for treatment of another CVA (new diagnosis), you should report the current CVA first (the 436 category), followed by any appropriate late effects code(s) (such as 438.30). This identifies those deficits that relate to the present CVA and from pre-existing conditions.

    "If a patient has a current CVA and deficits from an old CVA, ICD-9 2005 Guidelines does state that you may use codes from category 438 with codes from 430-437," says Janet O'Connor, CPC, assistant billing manager at UVA Physical Medicine and Rehab in Charlottesville, Va.

    Example 3: If the patient has no residual problems from the first CVA, you may report V12.59 (Personal history of certain other diseases of circulatory system; other) as the secondary diagnosis, according to Section 1.C7.B of the Guidelines.

    5. Describe Unnamed CVA Conditions

    Two codes in the 438 series require you to add a secondary code "because they are nonspecific and you need another code to be as specific as possible," Becker says.

    The first is 438.89 (Other late effects of cerebrovascular disease). When ICD-9 does not list the patient's residual condition, use this along with a second code to provide further detail. For a patient who has urinary incontinence due to CVA, you should report 438.89 followed by 596.59 (Other functional disorder of bladder) and 788.39 (Other urinary incontinence).

    The second code in this category is 438.5x (... other paralytic syndrome). ICD-9 may not specify the patient's paralytic syndrome in the 438 series, so you might use 438.5x and another code, such as 344.00-344.09 (Quadriplegia and quadriparesis), to indicate the type of the patient's paralysis.

    Note: You can find the official ICD-9-CM Guidelines for Coding and Reporting at
     http://www.cdc.gov/nchs/data/icd9/icdguide.pdf

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