Coding Compliance CVA Residual Effects

Coding CVA’s, meaning Cerebral Vascular Accident caused by a blood clot or a hemorrhage, or what the patient calls a stroke can be a challenge in home care.  Coding guild lines do not allow the acute code for the specific type of cerebrovascular event to be coded in M1020 or M1022.  These specific does are only allowed to be used in the inpatient settings.

Therefore, what is allowed to be coded in homecare is the Late Effects of Cerebrovascular Disease group of codes.  Late effects mean residual effect on sequelae of the initial acute cerebrovascular event.  These codes are found in the 438.0 to 439.9 category.  In the alphabetical index to Diseases they are found under the word Late Effects: subheading cerebrovascular disease.

In home health, the nurse and therapist are adhering and treating the lingering deficits that the CVA has caused.  Rehabilitation has started in the acute hospital and progressed in the inpatient rehabilitation.  Now, that the patient is home, further therapy helps to regain function in the variable of home setting, as long as the patient remains homebound.  Otherwise, therapy would continue in an outpatient clinic or office.

To code these late effects of cerebrovascular disease, the coder needs to identify what these lingering residual effects are.  It is very important that the clinician completing the OASIS and initial assessment state clearly what these residual effects from the stroke are.  Different late effects have a different code. There are 29 different codes to pick from, so concise information is needed.  Please never document CVA or late effects of CVA without following these words with the specific affects the patient presents.

It is acceptable to list more than 1 deficit, especially if multiple therapies are ordered.  It is also necessary to indicate, if there is hemiplegia or monoplegia, what side of the body is affected. The coding guidelines want to know if the dominant side is affected or the non-dominant side and if it is upper or lower limbs for monoplegia.  Documenting left or right hemiplegia from a CVA does not help the coder if it is not known if the patient is right or left handed.

To recap: never document CVA or late effects of a CVA on the diagnosis list without also coding what the specific residual effects are.  These residual effects will be a focus of care for the clinician and therapist as seen by the orders and goals on the Plan-of-Care.