late effects

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Joined: Fri Feb 13, 2015 4:05 pm

Fri Feb 13, 2015 4:47 pm

I need some guidance on how to code for the scenario below. The provider coded late effects, the outside auditing company didn't code anything except the infarct and I am thinking about coding the infarct, aphasia and facial droop (not as late effects). The pt has a hx of a previous infarct but nothing was documented about any residual effects from the infarct.
A/P: Acute ischemic infarct with severe expressive aphasia and r facial droop.
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Tue Feb 24, 2015 1:27 pm

The expressive aphasia and facial droop would be symptoms of the ischemic infarct and therefore should not be separately reported. Per ICD-9 guidelines “signs and symptoms that are associated routinely with a disease process should not be assigned as additional coeds, unless otherwise instructed by the classification”
It also should not be classified as a late effect when it’s associated with an acute CVA. Refer to ICD-9 Coding Guideline C.7.d.1) “Category 438, Late Effects of Cerebrovascular disease”
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