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.