September 15, 2014

HCPCS Code J3490 Medicare Reimbursement Billing Guidelines

Learn HCPCS Code J3490 billing guidelines for Medicare Reimbursement. It is used for non-coded drugs unlisted NDC number.

HCPCS Code J3490 Medicare Reimbursement Billing Guidelines

J3490 Medicare Reimbursement and Coverage

The Healthcare Common Prodecure Coding System (HCPCS) is a collection of codes that represent procedures, supplies, products and services which may be provided to Medicare beneficiaries and to individuals enrolled in private health insurance programs.

CMS Medicare offers two codes for unlisted drugs: J9999 Unclassified Chemotherapy Drugs and J3490 Unclassified drugs for others. The more commonly used unlisted drug code is J3490. With an unlisted drug code, it is needed to document the importance of trying this new drug and record it in the chart notes. If the physician tried listed drugs and they didn't work, you need to make sure the claim includes that information.

The main drugs that now require unlisted codes are Neulasta and Faslodex, both of which are non-chemotherapy drugs and therefore require J3490. The two main chemotherapy drugs that require J9999 are Velcade and Oxaliplatin.

HCPCS Code J3490 Billing Guidelines

HCPCS code J3490 is a non-specific code that should be used only when another J-code does not describe the drug being administered (CMS has not assigned a specific 'J' code to the drug used). The appropriate 'J' code should be used if one has been assigned to the drug. For the drug with no assigned 'J' code, the name, strength of the drug (if applicable) and the actual dosage administered must be indicated on the CMS-1500 form in Block 19 or Block 24 (listed with the procedure code).

If the drug is compounded, the invoice/acquisition cost must be included with the description. This would ensure proper adjudication of your claim for J3490. Billing requirements for HCPCS codes J3490 (Unclassified Drugs) and J3590 (Unclassified Biologics) are as follows:
  • Providers may submit claims for J3490 and J3590 only when a specific code for the drug is not available or does not exist.
  • The claim form must include the following information in the Remarks field (Box 80)/Reserved for Local Use field (Box 19) of the claim form or on a separate attachment:
    1. Name and Strength of Drug Administered
    2. Amount Given
    3. NDC Number

J3490 NDC number for Drugs Unlisted

If the name, strength and dosage administered of the drug are not all listed, the claim will be denied for lack of information necessary to process the claim. At present, Railroad Medicare cannot identify a drug by only the NDC number.

For billing of compounded drugs administered via implanted pump, submit a single combined line item for all drugs with HCPCS Code J3490 and bill the combined charges for all drugs.

For Electronic Claims
Indicate the name(s) and dose(s) of each drug being submitted in the documentation record.

For Paper Claims
  • Indicate Compunded drugs, invoice attached in Item 19 of the CMS-1500 Claim Form
  • Abbreviations are acceptable, but must use industry acceptable abbreviations (e.g., 'MS' for morphine sulphate)
  • Billed amount must be the invoice price for the compounded drug(s). To indicate this, we suggest using 'INV' next to the price (e.g INV $250.00)

September 8, 2014

CPT Modifier 59 changes 2015 under Distinct Procedural Service

Learn about changes related to CPT Modifier 59 reimbursement and use guidelines under Distinct Procedural Service, effective from January 2015.

Important CPT Modifier 59 changes are coming one of the frequently used and misused modifier for Medicare reimbursement of CPT Codes in Acupuncture, Breast Biopsies, Physical Therapy, Radiology, Surgery and other medical practices.

On August 15, 2014 CMS released the final ruling for the appropriate Modifier 59 use and the changes that will take effect on January 1, 2015. It is critical that all coders and providers be made aware of the changes to the utilization of Modifier 59 (Distinct Procedural Service) that will go into effect starting from 2015.

CPT Modifier 59 changes 2015 under Distinct Procedural Service

Transmittal 1422, CR8863 details new modifiers to be used in place of modifier 59. The new modifiers will impact NCCI (National Correct Coding Initiative) edits utilized by CMS MAC Carriers.

Studies have shown that the modifier 59 is both commonly used and commonly abused. According to the 2013 CERT report $2.4 billion was paid on claims containing modifier 59 with a projected error rate of $450 million USD. The error rate is not exclusively attributed to modifier 59, but if only 10% of those found to be in error were due to the modifier 59, that would represent a $45 million damage.

CPT Modifier 59 changes 2015 under Distinct Procedural Service

CMS has established new HCPCS modifiers to define subsets of modifier 59 which was previously used to define a "Distinct Procedural Service" CMS will continue to recognize modifier 59.

However due to the over utilization of Modifier 59, it should not be used beyond December 31, 2014. As a default, at this time CMS will initially accept either a -59 modifier or a more selective – X{EPSU} modifier as correct coding. Although the rapid migration of providers to the more selective modifiers is encouraged.

These modifiers are valid modifiers even before national edits are in place, so contractors are not prohibited from requiring the use of selective modifiers in lieu of the general -59 modifier when necessitated by local program integrity and compliance needs.

CPT Modifier 59 Replacement Use

Therefore, our recommendation for all providers, coders and medical billing companies is to prepare to replace utilization of Modifier 59 with the distinctive descriptors as follows:
  • XE Separate Encounter: Service That Is Distinct Because It Occurred During A Separate Encounter
  • XS Separate Structure: Service That Is Distinct Because It Was Performed On A Separate Organ/Structure
  • XP Separate Practitioner: Service That Is Distinct Because It Was Performed By A Different Practitioner
  • XU Unusual Non-Overlapping Svc: Use Of A Service That Is Distinct Because It Does Not Overlap usual components of the main service
These modifiers, are referred to as -X{EPSU} modifiers, and define specific subsets of the -59 modifier. CMS will not stop recognizing the -59 modifier but notes that CPT instructions state that the -59 modifier should not be used when a more descriptive modifier is available.

CPT Modifier 59 Reimbursement Guidelines

To prepare and work well with CPT Modifier 59 changes 2015 under Distinct Procedural Service, we recommend the following steps to be taken:
  1. Always use the subset more descriptive Modifier EPSU’s. CMS will continue to recognize the -59 modifier in many instances but may selectively require a more specific –X{EPSU} modifier for billing certain codes at high risk for incorrect billing.

  2. All Medical Billing Practices should monitor the use of modifier 59 to ensure that it is currently being utilized appropriately.

  3. All Medical Billing Practice Managers should check with their medical coder or medical billers to insure they are prepared for this modifier 59 alteration.

  4. All Medical Billing and Coding Specialist should inform their providers. Make sure that there are no defaults set up in their Practice Management Software System, that automatically default modifier 59.

  5. Ensure the proper documentation of any distinct service.

Happy Coding! and keep visiting us to stay on top of all the continuing Medical Billing and Coding updates and changes.

September 1, 2014

Medical Billing and Coding Updates, Changes & News 2014

Medical Billers and Medical Coders are healthcare trained experts that document all the information related to patients visits, their medical charts and everything about treatment in the form of medical codes for the reference of the patients and provider and particularly insurance payers. Medical coding jobs are in high demand and Medical Billing is an excellent career.

However, since this is a dynamic field which which requires to be regularly updated. Let's, look at the most important Medical Billing and Coding Updates, Changes & News of year 2014:

Medical Billing and Coding Updates, Changes & News 2014

Revised CMS 1500 Form

The Centers for Medicare and Medicaid have released a revised claims form that will be distributed for use on January 6 and become mandatory by April 1. The new form has been created to accommodate ICD-10 come October. Check with your payers for their projected effective dates.

The biggest change on the new claim form is the inclusion of eight additional areas for healthcare providers to list diagnosis codes associated to the claim. The current version only allows four spaces per claim to list related diagnosis codes. Other fields have been removed or changed as well. For example, the new claim form will no longer ask for marital status, employment status or the insured’s employer/school name.

CPT Code Changes 2014

The American Medical Association's current procedural terminology code set will experience a massive overhaul at the start of next year. In September, 353 changes were announced, many of which pertain to technology improvements. As Ardis Dee Hoven, M.D, President AMA said:
The CPT code set is the foundation upon which every element of the medical community; doctors, hospitals, allied health professionals, laboratories and payers; can efficiently share accurate information about medical services. The latest annual changes to the CPT code set reflect new technological and scientific advancements available to mainstream clinical practice and ensures the code set can fulfill its vital role as the health system's common language for reporting contemporary medical procedures.
This is considered to be the largest CPT code modification in years. The 2014 CPT codes and descriptors can be purchased and imported directly into existing claims and billing software using this downloadable CPT 2014 Data File.

Healthcare Exchanges (HIX)

How HIXs will set payment rates is still an uncertainty, but some states are already aligning with Medicaid prices, resulting in lower reimbursement rates for doctors. Couple lower payments with an influx of thousands of new patients and practices are facing some serious jumps in costs.

Mitigate underwhelming reimbursements by implementing new technologies like an EHR/EMR and comprehensive practice management solutions that streamline your workflow and help move patients through your practice faster, a quality that will be vital as you look to take in more patients to cancel out decreases in revenue.

Quality Reporting

The quality reporting program managed by the Centers for Medicare & Medicaid Services will be able to levy penalties for noncompliance in 2014. Providers are required to complete checklists that review the quality standards of routine procedures and surgery for patients who are enrolled in Medicare or Medicaid.

Quality reporting. Penalties for noncompliance with CMS' quality reporting program will commence next year. The use of G-codes on Medicare claims for five types of adverse events started Oct. 1, 2012, and has grown over the last year to include safe surgery checklist use and volumes of certain procedures. Any ASCs that did not successfully report G-codes on at least 50 percent of Medicare claims between Oct. 1, 2012, and Dec. 31, 2012, will experience a 2 percent reduction in payments beginning in 2014.

Ambulatory surgery centers that failed to comply with G-code reporting standards between October and December 2012 will receive a 2 percent reduction in the reimbursement amount for Medicare claims. This penalty will also be applied to ASCs that fail to comply in the future, so it is essential for providers to be proactive about compliance.

The reimbursement reduction will be continual. Billing staff members must keep complying with the quality reporting measures to avoid penalties in 2015 and 2016.

ICD-10 Implementation

The long-anticipated, new International Classification of Diseases code is dealyed for one year and will finally take effect on October 1, 2015. But most of the Healthcare industry is expected to spend year 2014 preparing for upcoming ICD 10 rollout. Healthcare providers should expect potential billing and coding impediments and possible profit reductions during this massive healthcare billing overhaul. You'll have to start training for the switch as soon as possible to help reduce the impact.

CD-9 codes have been used in the United States for more than 30 years. There are only about 13,000 codes for the entire gamut of medical services that can be provided. ICD-10 replaces the outdated terminology and requires more specific documentation as well as more details about the service that was provided. The requirements for greater documentation are expected to increase the quality of care. Experts say the type of documentation providers will be required to submit for billing purposes is the type of documentation they should already be using if they are providing proper medical services.

Medical Billing Software based on HIT

Changes in patient volume will force medical offices to move to digital Medical Billing Softwares. While most offices have already switched to digital medical coding and billing, approximately 20 percent of hospitals and nearly half of physicians still need to make the change.

Expanded access to insurance is sure to increase patient volume significantly. Medical offices that struggle to manage paperwork will not be able to keep up with the change in volume without the help of computer programs. Outsourcing medical coding and billing is one way to benefit from digital processing without the need to purchase a software package or take the time to train administrative professionals on the changes in medical coding and billing.

Medical coding and billing changes in 2014 bring unique challenges for providers and their medical billing staff. Ultimately, physicians have to prepare for these billing changes if they want to keep receiving the appropriate reimbursements for services rendered. Make sure your billing department is updated in compliance with regulations put into place under the Affordable Care Act.

August 25, 2014

CPT Code 99214,99213 E/M Coding Established Office Patient Correctly for Medicare Reimbursement

Learn how to correctly bill CPT Code 99214 instead 99213 or 99212 for Evaluation and Management (E/M) Coding of Established Office Patient to increase revenue through legitimate Medicare reimbursement.

The CPT Code 99214, if billed correctly, can increase revenue for the practice. By only using CPT code 99212 and CPT code 99213 many providers are losing thousands of dollars in legitimate revenue yearly. Which can be avoided with the correct billing of the 99214 E/M Code.

CPT Code 99214,99213  E/M Coding Established Office Patient Correctly for Medicare Reimbursement

CPT Code 99214 is assigned to the medical service that complies with the following requirements:
  1. The patient is an established one, meaning is not their first visit.
  2. It must be an outpatient visit, meaning it must not incorporate a day of hospital time.
  3. It must meet or exceed to of the following three points:
    1. A detailed medical history
    2. A detailed medical exam
    3. A medical decision that entails moderate complexity.
  4. The severity of the problem that brings the patient to the clinic must be from a moderate to a high one. 5. And last, the doctor and the patient should have a maximum of 25 minutes face time.

CPT code 99214 Increases Medicare Revenue

Medicare and other Insurance are pleased to pay the lesser money to providers if they (the doctors) are willing to under use the CPT code 99214. The key to using this code correctly is to understand the proper use and the components required to fully capture the most out of all of your encounters. As a provider, you will be rewarded the fruits of your labor when you take the time to learn the components of this code and use it properly.

When you consider CPT code 99214 it has a higher return rate linked to it, however, it must fall under the purview of a moderate complexity to a high severity problem. The physician, if using time as a factor must have spent at least 25 minutes in a face to face scenario with the patient. However, the time component is only a guide and not completely required if the components are included in the visit and the required medical necessity is present. The physician must be able to furnish the two or three areas which include history, physical exam and medical decision making with the proper documentation when filing for the CPT code 99214.

The patient encounter, composed of a detailed history, detailed patient exam and moderate complexity in the medical decision making will justify the use of CPT code 99214 as long as the medical necessity is apparent.

For example, you have an established office patient with hypertension, diabetes and a history of dyslipidemia who you are seeing on follow up in the office. Under the 1997 guidelines you can use three chronic and stable conditions to qualify for the higher code within the history component.

Document the medications and the review of systems along with the proper past medical, family and social history and the first component is met. Document the proper physical exam using appropriate organ system approach six areas with two bullets each and you have met the requirement for the complexity on this area.

At this point, technically you have reached the level 4 criteria since there only needs to be two out of three components required for an established patient.

However, we feel that it is difficult to not have a medical decision making component so we include that into our progress note. You can document the lab results for the patient and further solidify the visit to qualify at the higher code. As long as the medical necessity is present to justify the work done during the visit the coding can be at the higher level.

99214 vs 99213 CPT Codes Billing

In above Example, most providers will code the example as a CPT 99213, however, the qualifiers are present for the higher 99214 code.

While evaluating three different medical problems such as Hypertension, Diabetes and Hyperlipidemia, using the 1997 rules, you have met the medical necessity component as well, due to the need to monitor these diseases and help the patient with his/her control.

However, meeting the proper criteria required to code the encounter will enable a medical biller to get the rewards for the his career and his practice. It also become important, becaue now days Medical Billing and Coding Business are facing potential cuts in the reimbursements for the services the bill.

August 18, 2014

Sentinel Node Biopsy (SNLB) Coding for Breast Cancer/Melanoma

Coding Sentinel Node Biopsy (SNLB) is a surgical procedure in Melanoma and Breast Cancer Screening to determine if the cancer has spread beyond a primary tumor into the lymphatic system. Sentinel Node Biopsy in Breast Cancer Evaluation reveals cancer spread, then patient needs additional lymph nodes removed.

The Sentinel Nodes are the first few lymph nodes into which a tumor drains. Lumpectomy with Sentinel Node Biopsy for Melanoma involves injecting a tracer material that helps the surgeon locate the sentinel nodes during surgery. The sentinel nodes are removed and analyzed in a laboratory. If the sentinel nodes are free of cancer, then cancer isn't likely to have spread and removing additional lymph nodes is unnecessary.
Sentinel Node Biopsy (SNLB) Coding for Breast Cancer/Melanoma

Sentinal node biopsy is not the same as Lymphadenectomy. Thus and confusing the two could have direct effects on the accuracy of your Medical Billing Claims.

Sentinel Node Biopsy (SNLB) Coding

Please follow given points to be sure you get all your Sentinel Node Biopsy procedures billing claims reimbursed:

Sentinel Node Biopsy is Billable when Results Lead to Subsequent Excisions

When the surgeon performs a sentinal lymph node biopsy prior to an unplanned partial mastectomy (either with or without lymphadenectomy) and the subsequent excisions are a result of biopsy findings, you may report the sentinal node biopsy separately. As according to guidelines set forth in Chapter 3 of the National Correct Coding Initiative Policy Manual for Medicare Services:

Sentinal Lymph Node Biopsy is separately reported when performed prior to a localized excision of breast or a mastectomy without Lymphadenectomy.

Therefore you can report both sentinal lymph node biopsy and lymphadenectomy during the same session as long as:
  1. The lymphadenectomy is unplanned at the time of the biopsy.
  2. The decision to perform lymphadenectomy (at the same or a later session) is based on the results of the biopsy.
For Example: The surgeon takes a biopsy of the sentinal axillary node (38525, Biopsy or excision of lymph node[s]; open, deep axillary node[s]). The pathology report indicates that the malignancy has spread, so the surgeon follows up with a lymphadenectomy (for example, 38745, Axillary lymphadenectomy; complete) to remove the affected tissue.
In this case, because the biopsy led to the decision to perform the mastectomy, you may report both 38525 and 38745.

Many payers will require that you append modifier 59 (Distinct procedural service) to the appropriate biopsy code (38500-38530) to further differentiate the procedure from the follow-up lymphadenectomy. In addition, your documentation should make clear that the biopsy results provided the justification for and led to the decision to perform the subsequent excisions.

Bundle Sentinal Node Biopsy with Lymphadenectomy

You should not separately report Sentinal Node Biopsy (38500-38530) and a planned lymphadenectomy (38700-38780) in the same region during the same operative session. Instead, you should include the sentinal node biopsy in the more extensive, same-location lymphadenectomy. Medicare says:
Sentinal lymph node biopsy for malignant melanoma is eligible for reimbursement unless a regional lymphadenectomy is planned, regardless of the findings of the [biopsy].

If the surgeon prospectively plans to perform lymphadenectomy, you should not separately report a sentinal node biopsy. In this case, the complete lymphadenectomy automatically includes removal of any lymph nodes that would qualify as sentinal nodes.

You should consider sentinal node biopsy (38500-38530) to be a more "targeted" and less invasive procedure than lymphadenectomy (38700-38780).

The sentinal node is the first lymph node to receive drainage from a cancer-containing area of the breast (or other site). If the sentinal lymph node is negative for metastases, the surgeon need not perform a complete lymphadenectomy (which removes a much greater volume of tissue), thereby avoiding the morbidity and complications associated with that procedure.

Keep in mind, however, that the above sequence of events would be rare. The purpose of a sentinal node biopsy is to avoid a lymphadenectomy, if possible. Therefore, surgeons generally perform lymphadenectomy only if the results of the sentinal node biopsy show malignancy.

Excisions, not Incisions, Count for Sentinal Node Coding

When the surgeon performs more than one sentinal lymph node biopsy, you should realize that the number of incisions, not the number of biopsies, determines the number of codes and/or units.

If the surgeon performs two biopsies through the same incision, you may report only a single code. If the surgeon takes three biopsies from two different incisions, you may report two codes, etc.

When reporting more than one biopsy code, append modifier 59 (Distinct procedural service) to the second and subsequent codes.
Example: Using one incision, the surgeon biopsies a superficial node and a deep axillary node. In this case, because the surgeon accesses the node through a single incision, you may report only the more extensive (higher-paying) code -- in this case, 38525.
If the surgeon performs the same procedures through different incisions, you may report 38525 and 38500, attaching modifier 59 to the lesser (lower-valued) procedure here, 38500 to indicate a separate anatomic area.

Watch for Mastectomy/Lymphadenectomy Unbundle

If the surgeon performs a mastectomy and lymphadenectomy during the same session, you should report 19302 (Mastectomy, partial [e.g., lumpectomy, tylectomy, quadrantectomy, segmentectomy]; with axillary lymphadenectomy) for the combined procedure rather than reporting 19301 and 38745 separately.

Often, with partial mastectomy, the surgeon will perform a limited axillary lymphadenectomy to remove some lymph nodes. The surgeon may also remove the nodes in the axilla through a separate incision at the same time.

Look out for the Staged Exception

Following some partial mastectomies (19301), the surgeon may return during the postoperative period to see if there has been any lymph node involvement and, if so, may choose to remove the nodes at that time.

In such a case, you would report the lymphadenectomy as a staged procedure using 38745 with modifier 58 (Staged or related procedure or service by the same physician during the postoperative period) appended.

Sentinel Node Biopsy CPT Codes

Sometimes when performing a partial mastectomy it is necessary to remove axillary lymph nodes or biopsy the sentinel node. A sentinel node is the first node in a lymphatic chain to receive fluid from the primary tumor site which contains the metastisizing cancer cells.

CPT code 19301 is reported for a partial mastectomy or lumpectomy when the tumor is removed and specific attention is paid to the surgical margins. The lymph node excision code is determined by the type of procedure performed.

There are 3 levels of axillary lymph nodes Levels I-III. CPT code 38500 is reported for open excision or biopsy of superficial lymph nodes - these nodes are usually palpable under the skin. Levels II and III are deep and reported with CPT code 38525 (open, deep axillary nodes). The depth of dissection should be documented in the op note for coding accuracy.

Injection of dye to confirm a sentinel node is separately reported with CPT code 38792 (injection procedure for identification of sentinel node).

CPT code 19302 is only reported when "all identifiable axillary lymph nodes are removed" – A separate incision may be made but that is not what determines coding, reporting is based on the extent of axillary lymph node dissection.

Sentinel Node Biopsy ICD 9 Code

While coding Sentinel Node Biopsy/Surgery , the ICD 9 diagnosis code(s) must be represent the condition of the patient.

When the ICD-9-CM diagnosis codes 172.0-172.9 are used to identify malignant melanoma of the skin. The patient records must document that the tumor is Clinical Stage I.

When ICD-9-CM codes 174.0-174.9, 175.0, or 175.9 are used to identify breast cancer, the patient records must document that the tumor is Clinical Stage I or II.

August 11, 2014

CVA Stroke (Cerebral Vascular Accident) Coding and Billing

A cerebral vascular accident (CVA), commonly referred to as a stroke, is a general term used to describe any disturbance in cerebral circulation that results in ischemia and anoxia. Stroke is a major cause of death and disability in the United States. It is also one of the top 10 conditions leading to hospital admission in the United States, involving more than 1 million hospitalizations in 1998. This column will cover various aspects of coding cerebrovascular diseases and will prepare you for questions on the certified coding specialist (CCS) or CCS-P (physician-based) exams related to them.

CVA Stroke (Cerebral Vascular Accident) Coding and Billing

A stroke occurs when blood vessels carrying oxygen to a part of the brain suddenly burst or become blocked. When blood fails to get through to the affected parts of the brain, the oxygen supply is cut off and brain cells begin to die. Strokes fall into several major categories, based on whether the disrupted blood supply is caused by a blocked blood vessel (ischemic stroke) or a hemorrhage. Ischemic strokes account for 80 percent of all strokes. As part of the medical evaluation for stroke, doctors regularly use head CT to rule out hemorrhagic stroke.

Nonhemorrhagic Stroke

Thrombosis: A blood clot (thrombus) forms inside an artery in the brain, blocking blood flow. The clot may occur in the cerebral, carotid or vertebral arteries.

Embolism: A clot, originating somewhere other than the brain, breaks loose and is carried by the blood stream to the brain. The clot reaches a point where it can go no further and plugs the vessel, cutting off the blood supply.

Hemorrhagic Stroke

Subarachnoid hemorrhage: The bleeding occurs in the space between the brain and the skull.

Intracerebral hemorrhage: A defective artery within the brain bursts, flooding the surrounding brain tissue with blood.

Hemorrhagic strokes are frequently caused by aneurysms. Another cause of hemorrhagic strokes is an arteriovenous malformation (AVM), which is a cluster of abnormal blood vessels.

The symptoms of CVA vary in type, severity and permanency. Some of the symptoms eventually subside, while others are never completely resolved. Warning signs of a stroke include:
  • Sudden weakness or numbness of the face, arm or leg on one side of the body.
  • Sudden dimness or loss of vision, particularly in one eye.
  • Sudden difficulty speaking or understanding language.
  • Sudden severe headache with no known cause.
  • Unexplained dizziness, unsteadiness or sudden falls, especially with any of the other signs.

Coding Cerebrovascular Disease

Codes from categories 430-434 should be used when coding the initial episode of care for an acute cerebral hemorrhage, occlusion, thrombosis, infarction or stroke.
  • 430, Subarachnoid hemorrhage
  • 431, Intracerebral hemorrhage
  • 432, Other and unspecified intracranial hemorrhage
  • 433, Occlusion and stenosis of precerebral arteries
  • 434, Occlusion of cerebral arteries
The coding of strokes has been problematic for coders because the record may not be clear on whether the cause was hemorrhagic or nonhemorrhagic. In ischemic or nonhemorrhagic strokes, the artery affected should be identified. Documentation must also indicate whether or not there is an infarction. An infarct is an area of necrosis, or tissue death, due to obstruction of a blood vessel by a thrombus, embolus or a hemorrhagic or ischemic event. In hemorrhagic strokes, the site of the hemorrhage should be documented.

Codes from Categories 433, Occlusion and stenosis of precerebral arteries and 434, Occlusion of cerebral arteries use a fifth digit to indicate the presence or absence of an infarct during the current episode of care. A fifth digit of 1 is reported when there is documentation of a cerebral infarction. A fifth digit of 0 is used when a cerebral infarction is not documented. The coder should never assume that an infarction has occurred without this being clearly identified in the medical record. Always query the physician when the documentation is incomplete or unclear.

For example: A 62-year-old male is diagnosed with an acute cerebral infarction due to thrombosis. The patient also has a known history of bilateral carotid stenosis. Assign code 434.01, Cerebral thrombosis with infarction, as the principal diagnosis. Assign code 433.30, Bilateral carotid stenosis without infarction, as an additional diagnosis. The fifth digit "1" cannot be applied to the bilateral carotid stenosis because the physician has made no mention of an infarction in that specific location.

Code 436, Acute but ill-defined cerebrovascular disease, is used when the medical record documents apoplectic attack, cerebral apoplexy, apoplectic seizure or cerebral seizure. It is very important to remember that code 436 is no longer the "default" code for CVA or stroke, not otherwise specified. Effective Oct. 1, 2004, the inclusion terms of stroke and CVA under code 436 have been removed and re-indexed to code 434.91, Cerebral artery occlusion, unspecified, with cerebral infarction. An embolic stroke or CVA will now code to 434.11, Cerebral embolism with cerebral infarction, and a thrombotic stroke or CVA will now code to 434.01, Cerebral thrombosis with cerebral infarction. With these changes, stroke and CVA not otherwise specified will always be coded as with infarction.

It is very important to note that even though this is an addenda change, and does not involve code changes, it has significant consequences for the coding professional. This change was made because physicians use the clinical terms of stroke and CVA synonymously with cerebral infarction. Records also lack specificity in the documentation and the change will allow improved uniformity and statistical data, and prevent unnecessary queries to the physician. Because coders had been accustomed to assigning code 436 for a diagnosis of CVA, when no additional information is available, care must be taken to break this habit because reimbursement will be affected.

The Medicare Grouper assigns code 434.91 to DRG 14 as it did in the previous version; however, because CVA now codes to 434.91 instead of 436 the reimbursement is higher because DRG 14 will be assigned not DRG 15.

Codes from category 437 are used to identify other and ill-defined cerebrovascular diseases such as cerebral arteriosclerosis, nonruptured cerebral aneurysms and arteritis and transient global amnesia.

Each component of the diagnosis documented by the physician identifying cerebrovascular disease should be coded unless the alphabetic index or the tabular list instructs otherwise.

For example: cerebrovascular arteriosclerosis with subarachnoid hemorrhage due to ruptured aneurysm is coded to 430 and 437.0. When codes from the 430-437 series are used, additional codes are needed to identify any sequelae or neurological deficits such as hemiplegia or aphasia. To be coded, residual neurological deficits must be present on discharge. For example, a patient admitted because of a CVA with associate aphasia would have only the CVA code if the aphasia cleared by discharge. However, if the aphasia is still present at discharge both codes 434.91 Cerebral artery occlusion, unspecified, with cerebral infarction and 784.3, Aphasia are assigned.

If there are no residual deficits and the symptoms abated in less than 24 hours, query the physician to ascertain the diagnosis of a CVA vs. transient cerebral ischemia or attack (TIA). Use an appropriate code from the category 435, Transient cerebral ischemia, when neurological deficits are of sudden onset and brief duration due to insufficiency of cerebral circulation. The deficit may last from 5 minutes to 24 hours and is referred to as reversible. By the time of discharge, the deficits have subsided with the possible exception of some weakness. Impending CVA, intermittent cerebral ischemia and TIA are synonymous with transient cerebral ischemia.

For example: A patient is admitted because of repeated, brief episodes of light-headedness and left-sided tingling over the past week. An emergency CT scan reveals no evidence of hemorrhage, fluid collection, mass or recent infarction. The physician documents impending CVA. The correct code assignment for the principal diagnosis is 435.9, Unspecified transient cerebral ischemia.

Once a patient has completed the initial treatment or is discharged from care, codes from category 438, Late effects of cerebrovascular disease should be assigned to identify the residual neurologic deficits or late effects of cerebrovascular disease.

Coding Late Effects of Cerebrovascular Disease

Category 438 is used to identify residuals or late effects of cerebrovascular disease when a patient is seen or admitted at a later date. These late effects include neurological deficits that persist after the initial onset of the cerebrovascular event.

For example: A patient is seen with hemiplegia on the dominant side due to an old CVA. Code 438.21, Late effects of cerebrovascular disease, hemiplegia affecting dominant side is assigned. Codes from category 438 may be assigned as the principal diagnosis when the reason for admission is to deal with the late effect.

However, if the admission is for rehabilitation a code from category V57, Care involving use of rehabilitation procedures is assigned as the principal diagnosis with an additional code from category 438.

For example: A patient is admitted for rehabilitation consisting of speech therapy, occupational therapy and physical therapy for residual aphasia and hemiplegia following a CVA. In this instance code V57.89, Other specified rehabilitation procedure, is assigned as the principal diagnosis. Codes 438.11, Late effects of cerebrovascular disease, Aphasia, and 438.20, Late effects of cerebrovascular disease, Hemiplegia affecting unspecified side are assigned as additional diagnoses.

Codes from category 438 may also be assigned as additional diagnoses when a patient is admitted with a new CVA and residuals from a previous episode remain at the conclusion of the visit.

When appropriate, a code from category V12.59, Personal history of other diseases of circulatory system may be used when a patient has a prior CVA but has no residual conditions. Personal history codes explain a patient's past medical condition that no longer exists and is not receiving any treatment. A history of an illness, even if no longer present, is important information that may affect the type of treatment ordered.

In some cases, the neurologic deficits diminish or disappear within weeks or months of the CVA, while in others the neurologic deficits persist. The degree of impairment varies from case to case. For example: A patient is admitted for routine cataract extraction and the history and physical examination indicates weakness of the left arm.

The physician documents old CVA as a secondary diagnosis. There is no other supporting documentation regarding this diagnosis. In this instance, query the physician to determine the source of the left arm weakness because the physician did not state that the weakness was the result of the old CVA. If the physician documents that the arm weakness is not due to the old CVA, assign code V12.59, Personal history of other diseases of the circulatory system, for the history of old CVA.