Q&A: Reporting CVA and hemiplegia

Q: If the primary diagnosis is cerebral vascular accident (CVA), can we leverage the secondary diagnosis of hemiplegia to add a CC? Or is this considered in the same Major Diagnostic Category (MDC), Diseases and disorders of the nervous system?

A: Hemiplegia is not considered integral to a CVA so the two conditions can be coded together. If the physician documents the hemiplegia as being related to the CVA, it would be coded as a sequelae of the CVA which would require two codes—one for the condition or nature of the sequelae and a code for the sequelae itself. There is no time frame as to when the late effect code can be used, as long as the acute phase of the condition (CVA) is over.

We want to make sure there is a good medical history on these patients to see if they have suffered from a previous CVA that could be the cause of the hemiplegia. The documentation needs to clearly differentiate between a new onset manifestation versus one related to a previous condition.

Editor’s Note: Sharme Brodie, RN, CCDS, CCDS-O, CDI education specialist and CDI Boot Camp instructor for HCPro in Middleton, Massachusetts, answered this question. For information, contact her at sbrodie@hcpro.com. For information regarding CDI Boot Camps, click here.