How to Code Sequela of CVA in Home Health
Things to remember when coding Sequela of CVA:
A sequela is the residual effect (condition produced) after the acute phase of an injury or illness has terminated. Sequela of cerebrovascular disease, including acute CVAs, are coded using I69 codes. If there are no sequela present after a CVA or TIA, use Z86.73, Personal history of TIA and cerebral infarction without residuals, instead. The sequela of cerebrovascular disease may be present from the onset or may arise at any time after the onset of the condition. It is not appropriate to assign codes from subcategory I69.9 for residuals or sequelae of strokes because this code indicates unspecified cerebrovascular disease. Instead the default category for sequela of strokes NOS is I69.3. Some I69 codes are combination codes that include the residual deficit within the code, e.g., I69.351, Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. Others codes require additional information in the form of a secondary code to further specify the deficit, e.g., I69.391, Dysphagia following cerebral infarction. There is a “Use additional code” note indicating that an R13.1- code should also be used to further indicate the type of dysphagia.
A 79-year-old male was admitted to home health after being treated inpatient for an acute CVA. He experienced right sided weakness, dysphagia, and stuttering. He has previous comorbidities of hypertension and Type 2 DM (documented as well-controlled). After receiving care at an inpatient rehab facility, the patient is being referred to home health for nursing care, physical therapy, and speech therapy. The patient was started on Coumadin, for which he will require PT/INR monitoring and he also takes Insulin. The focus of care for this patient is hemiparesis.
- M1021a: I69.351 – Hemiparesis following cerebral infarction affecting right dominant side
- M1023b: I69.391 – Dysphagia following cerebral infarction
- M1023c: R13.10 – Dysphagia, unspecified
- M1023d: I69.323 – Fluency disorder following cerebral infarction
- M1023e: I10 – Essential primary hypertension
- M1023f: E11.9 – Type 2 DM without complications
Additional Diagnoses: Z79.01 (Long-term use of anticoagulant), Z51.81 (Encounter for therapeutic drug level monitoring), Z79.4 (Long-term use insulin).
- Three CVA sequela codes are needed to cover the residual deficits, one for the hemiplegia, one for the dysphagia, and one for the stuttering (fluency disorder).
- Because there is no documentation of patient's dominant side, right-sided hemiplegia defaults to dominant.
- The directives for the code for Dysphagia following cerebral infarction (I69.391) tell you to use an additional code to explain the phase of swallowing affected. Without knowing the specified level of dysphagia, Dysphagia, unspecified (R13.10) is coded.
- Both hypertension and type 2 DM should be coded as both will impact the patient's care and recovery.
- The use of anticoagulants should always be coded as they are considered high risk medications.
- Because the patient uses insulin and is not a type 1 diabetic, the code for insulin use is assigned.