Wiki Combo code vs two codes?

[AnnesPics]

Hi everyone,

I'm hoping someone could help me out with a code I'm a bit confused about - Pt was diagnosed with Hemiparesis as a result of cerebral hemorrhage. Do I code the cerebral hemorrhage as primary, followed by hemiparesis as 2* diagnosis or is there a combination code I should be looking for? Unfortunately, this is all the information I have on a hospital log sheet.

Thanks in advance
Anne

 

[mitchellde]

Hi everyone,

I'm hoping someone could help me out with a code I'm a bit confused about - Pt was diagnosed with Hemiparesis as a result of cerebral hemorrhage. Do I code the cerebral hemorrhage as primary, followed by hemiparesis as 2* diagnosis or is there a combination code I should be looking for? Unfortunately, this is all the information I have on a hospital log sheet.

Thanks in advance
Anne

If this was a non traumatic cerebral hemorrhage then you need to look at the 438 codes which are late effect of cerebrovascular disease. However you should examine the documentation to be certain you have all the relevant information, you should never code from a log sheet only.

 

[rvalente]

Hi Anne,
When coding strokes, look at it in two ways - the acute and post acute stage.

In the acute stage or care setting, you use an acute code, such as 436.

In the post acute stage you will be coding the "late affects" of the CVA. For the late effects of hemiparesis you would code 438.20 which is a combination code - unless you know if it is the patient's dominate or non dominate side was affected. In that case, the 5th digit would be different.

Have to agree with Debra, you need proper documentation and a log sheet I'm afraid won't hold up in an audit