Posts tagged ‘342’

September 4, 2010

Watch diagnosis codes that exclude each other

Here is another question I recently received:

Question: We are having an audit, and the surveyors indicated the primary diagnosis is not supported by the secondary diagnoses: 781.2, 781.3, 728.87, V15.88, 438.84, 386.54

That the status post head injury from 20 years ago is important to the patient’s condition and abilities. We have argued this information is included in the comments, but did not see the need to code here.

This is the admission information included: 22 y/o female referred to therapy d/t decline in function and recent falls. Hx includes head trauma since age of 2 w/weakness/hypertonicity right side of body. Has had PT & OT since 2 years old. Lives w/parents, PLOF independent w/all transfers and ambulates w/o assistive device. She presents w/generalized weakness, ataxic gait & requires SBA w/transfers for safety.

Father refuses other therapy at this time.

Lisa says: This is a late effect of head injury, which means you code the residual deficits (conditions produced) first, followed by the late effects code. It appears that the patient has hemiplegia as a result of a head injury (described as weakness/hypertonicity right side of body). In addition, abnormality of gait (781.2) and ataxia (781.3) exclude each other, so they would not be coded together, nor would they be coded with hemiplegia.

Weakness and ataxia are part of the hemiplegia and would not be coded in addition. 438 is a late effects of CVA code, and the patient doesn’t appear to have had a CVA. (It is, unfortunately, common for coders to automatically think of the 438 series when coding hemiplegia, but remember that ONLY deals hemiplegia with stroke. Go to the 342 series for other hemiplegia.)

I would code this patient with 342.1x (fifth-digit decided by whether this is affecting dominant or non-dominant side), 907.0, V15.88.