Q&A late effects scenerio

[danielle lucero]

A patient was admitted in a come due to acute cerebrovascular thrombosis with cerebral infarction; the coma cleared by the fourth hospital day. Aphasia and hemiparesis were also present. The aphasia had cleared by discharge, but the hemiparesis was still present.

How would you code? Would you use the 780 codes or 438 codes?


Thank you

 

[Carolyn Heath]

You would use 780.01 for the coma and 438.20 for the hemiparesis. In addition, you would code 434.01 for the cerebrovascular thrombosis (cerebral thrombosis in ICD-9 book) with cerebral infarction because that was why the patient was in a coma. Even though aphasia was cleared by discharge, you would still code it because it was in the documentation. The code for aphasia is 784.3.

 

[danielle lucero]

Why wouldn't you code the aphasia with 438.11?

 

[Carolyn Heath]

My apologies. I was looking at the wrong code. You would code aphasia with 438.11.