Stroke Residuals and Late Effects Consume Significant Health Care Dollars

Cerebral vascular accident (CVA) or 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 U.S., involving more than 1 million hospitalizations in 1998. The residual and late effects of stroke continue to consume significant healthcare dollars. This column will focus on the coding of these residual condition and late effects. You will see from the following that there has been a significant recent change on the coding of residual conditions arising from a stroke.

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.

CVA Codes
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

Codes from categories 433 and 434 require a fifth digit to indicate the presence or absence of an infarction 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.

Neurological Deficits
When codes from the 430-434 series are used, additional codes are needed to identify any resulting sequelae or neurological deficits. Common neurological deficits include:

  • Cognitive deficits (i.e. perception, attention, memory)
  • Dysphagia
  • Disturbances of vision
  • Facial weakness
  • Paralysis
  • Speech and language disorders
  • Swallowing problems

First quarter 2010 Coding Clinic, effective April 1, 2010, provides new guidance on coding neurologic deficits caused by a CVS as follows:

“Report any neurological deficits caused by a CVA even when they have been resolved at the time of discharge from the hospital. This current advice supersedes information previously published in Coding Clinic.”

In addition, the ICD-9-CM Official Guidelines for Coding and Reporting have also been revised for FY 2010 as follow:

“Additional code(s) should be assigned for any neurologic deficits associated with the acute CVA, regardless of whether or not the neurologic deficit resolves prior to discharge.”

Prior to April 1 residual neurological deficits must have been present on discharge in order to be coded. This is a major change in coding guidelines for this condition. The reason for the change is that neurologic deficits affect the care the patient receives while they are in the hospital even if the deficit resolves prior to admission.

It is important to note here that 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 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. 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.

Late Effect of CVA
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. Use one of the following codes:

438.0 Cognitive deficits

438.1x Speech and language deficits

438.2x Hemiplegia/hemiparesis

438.3x Monoplegia of upper limb

438.4x Monoplegia of lower limb

438.5x Other paralytic syndrome

438.8x Other late effects of cerebrovascular disease

438.9 Unspecified late effects of cerebrovascular disease

These late effects include neurological deficits that persist after the initial onset of the cerebrovascular event. Codes from category 438 may be assigned with codes from categories 430-437, if the patient has a current CVA and deficits from an old CVA.

When appropriate, a code from category V12.54, Personal history of other diseases of circulatory system may be used when a patient has a prior CVA but has no residual conditions.

Take the following quiz to test your knowledge of coding residual and late effects of CVA.


1. A patient is admitted through the ED with a diagnosis of CVA. CT scan of the brain showed a thombotic infarction of the brain. The patient has a history of hypertension and is continued on meds. The patient experienced residuals of hemiplegia and aphasia but they were not present at the time of discharge. Which of the following is the correct code assignment?

a. 436, 401.9

b. 434.01, 401.9

c. 434.00, 401.9

d. 434.01, 342.90, 784.3, 401.9

2. A patient is admitted to the hospital after being found unresponsive at home. The physician documents CVA as the final diagnosis. The patient is transferred to a skilled nursing facility for intensive physical therapy rehabilitation for hemiplegia and aphasia. What would be the correct code assignment for the patient’s stay at the skilled nursing facility?

a. 434.91, 784.3, 342.90

b. V57.89, 438.11, 438.20

c. V57.89, 434.91, 784.3, 342.90

d. 438.11, 438.20

This month’s column has been prepared by Cheryl D’Amato, RHIT, CCS, director of HIM, hospital solutions, and Melinda Stegman, MBA, CCS, clinical technical editor, Ingenix.


1. d. 434.01 is assigned as the principal diagnosis because a cerebral thrombosis is documented. The fifth digit of 1 is assigned to show the infarction. The hypertension code, 401.9, should also be assigned because the patient is on medication for the condition. Codes for the hemiplegia and aphasia are also assigned to identify neurological deficits treated during the hospital stay even though they resolved prior to discharge. Note that this is a change from previous coding guidelines.

2. b. Assign code V57.89, Care involving other rehabilitation procedures, as the principal diagnosis to identify the multiple physical therapies provided to the patient. Codes 438.11, Late effect of cerebrovascular disease, speech and language deficits, aphasia and 438.20, Late effects of cerebrovascular disease, hemiplegia affecting unspecified side, are assigned as additional diagnoses to completely describe the patients condition.

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