Coding Late Effects of CVA

Cerebrovascular Accident (CVA) is more commonly known as stroke. CVAs occur when there is a disruption of blood flow to the brain. Survivors of CVAs often suffer from disabilities (late effects or residuals) that can impact physical, psychological and social aspect of their lives.

Generally, late effects are coded by listing the nature of the late effect followed by the cause of the late effect. However, coding the late effect of a CVA is an exception to this rule.

Cerebrovascular Accident  (CVA) (430 – 437) is reserved for acute care settings only.  Home health agencies routinely manage the neurological deficits or disabilities created by the CVA.  Agencies do not treat the patient during the onset/evolution stage of the CVA.

Category 438  Late effects of cerebrovascular disease can be used to report CVA’s in Home Health. If a patient does not exhibit any residuals, late effects, or sequelae of a CVA, then the coder should use the History of CVA/TIA code V12.54, if applicable.

Many codes in Category 438 are combination codes, therefore,  one code is used to describe the late effect. The combination codes in this category include both the nature of the late effect and the late effect.

  • 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

Example: A patient has hemiplegia of the non-dominant side and aphasia as a result of a recent CVA.
438.22  Late effect of CVA with hemiplegia non-dominate side.
438.11   Late effect Aphasia.

Category 438 also includes CVA late effect codes that require additional codes to further explain the late effect.

  • 438.8x Other late effects of cerebrovascular disease

Example: The patient has dysphagia, oropharyngeal phase as a result of a CVA two years ago.
438.82 Dysphagia (late effect of CVA)
787.23 Dysphagia, pharyngeal phase

When Category 438 does not list the patient’s residual condition, use code 438.89 along with a second code to further describe the patients late effect of the CVA. 

Example: The patient has generalized muscle weakness as a result of a CVA.
438.89 Other late effects CVA
728.87 Muscle Weakness (generalized)

Keep in mind, CVAs are a medical emergency, this is why acute CVAs (categories 430 – 437) can only be used in home care in limited circumstances, there has been no infarct.