Coding Compliance Late Effects of a CVA Part II of II
There are many occasions where weakness, dysphasia, aphasia are shown throughout the assessment, but unless documented as such we cannot conclude that these are complications of the CVA. In SmartScribe the musculoskeletal section is often used by agencies to show late effects of a CVA. There is a box marked hemiplegia, so please check that box and below that box it must be noted this is due to or related to CVA. If you are using your own documentation please include in the narrative which diagnosis are related or due to the CVA.
As an additional note if the late effects of a CVA or hemiplegia is used we will note code separately abnormality of gate or muscle weakness these are inherent to hemiplegia. Also, please specify whether the hemiplegia is on the dominant or non-dominant side so that we may use the best code for you.
In conclusion, in dealing with diabetic complications and late effects of a CVA please use the phrases “related to” or “due to” where appropriate so that we may use the most accurate codes as possible.
Coding Compliance Diabetic Complications – CVA Part I of II
Coding Compliance Diabetic Complication – Late Effects of a CVA Part I
Many times we see a diagnosis of diabetes and throughout the assessment we will see PVD, Neuropathy, Chronic Kidney Disease, Ulcers, and other diagnoses. We cannot code any of these complications unless they are documented as such. If you are using the SmartScribe documentation there is a special section marked endocrine status which will list all of the complication. So, please use this as it will make it very clear to us that these need to be coded as diabetic complications. If you are using your own agencies documentation please include in the narrative that these diagnoses are diabetic complications.
Also, if there an ophthalmic complication of diabetes, please note what type of complication it is so that your coding is not help up while we determine what it is.
Finally, please make sure that the codes used in M1020 and M1022 match the information shown in the endocrine status. Many times we see diabetes as a diagnoses, while in the endocrine status it will show diabetes type I or even uncontrolled diabetes. So, please make sure to document the correct type as well as all diabetic complications which must be verified by a physician.
Coding Compliance Open Wounds as a Primary Diagnosis
Open Wound as a Primary Diagnosis
Often we see the term open wound used as a diagnosis, especially as a primary diagnosis. This is a vague term and should be avoided, because it will need clarification before it can be coded. Did you know that an open wound can be referred to 10 or more different types of wounds? And each one of these wounds has a different code or codes.
Some of these different wounds are:
Decubitus Ulcer
Diabetic Ulcer
Venous Stasis Ulcer
Normally Healing Surgical Wound
Post-Op Wound Infection
Dehisced Surgical Wound
Traumatic Wound
Burn
Chronic Skin Ulcer
Abscess
Each one of these requires as different code. This stops the coding process until the nature and the origin and the location of the wound can be identified. All these variables change the code or codes assigned.
Trauma wounds are caused by an outside trauma to the body and they include:
Gun shots
Avulsions
Lacerations
Punctures
Not surgical
Surgical wounds are never coded as a traumatic wound. A superficial traumatic wound is not a full thickness wound and this includes:
Skin tears
Abrasions
Blisters
Skin tear is not coded as a traumatic wound unless it is exceptionally large or the skin flap has been lost. Remember when you’re tempted to write open wound on that diagnosis line, please stop and consider specifically what kind of wound is this and where is its location, and put that information on the diagnosis line instead.
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 cerebrovascularevent. 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 cerebrovasculardisease.
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.
Coding Compliance Completing The M1010 OASIS Assessment
If a patient was discharged from an inpatient facility in the past 14 days, then: M1010 needs to be completed. If applicable then M1012 and M1016 needs to be completed. Also please note that M1010 and M1016 are only to be used for diagnoses codes, and M1012 are only for procedure codes.
Most importantly, OASIS Guidelines state that “V” and “E” codes are not to be used in section M1010 and M1016. Some examples of common V code wordings are:
Aftercare
Attention to
History of
Status of
Fitting and adjustment of
Long term use of a drug
Other physical therapy
Therapeutic drug monitoring
Encounter for suture removal
If there are orders and goals related to these v codes please note they must be used in the correct section in M1020 and M1022 only.
It is important to document why a surgery or procedure was performed. Many times we don’t have a history and physical or an operative report.
Was there a fracture, osteoarthritis, or neoplasm?
It is imperative to know why the according procedure was performed as it will impact the coding process.
This will help to expedite your coding process and ensure that you are using the most correct codes possible.
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