CVA vs TIA

rsmonroe

I have a physician using CVA because the patient has had symptoms > 24hr. The symptom is left sided facial, arm and leg numbness. NIHSS 0 and GCS 15. CT was negative (we have no MRI), Carotid Doppler negative. Patient with hx of MI, CAD, systolic heart failure with AICD in place. Some hypotension only abnormal VS, labs unremarkable.

In addition patient is likely to discharge in 1 day after the P.T. evaluation. I'm wondering about clinical validity with the physician basing the diagnosis only on length of symptoms... especially with only "numbness". I was trying to find some information on this subject.

afrady@blr.com

Unfortunately there aren't any coding guidelines which will be particularly helpful.  There is 4thQ 2017 pg 110 which states: "If after querying, the attending physician affirms that a patient has a particular condition in spite of certain clinical parameters not being met, the facility should request the physician document the clinical rationale, and be prepared to defend the condition if challenged in an audit."

However it sounds like he HAS listed his rationale, the continued numbness beyond 24 hours.

I am not a neurologists or MD, however literature suggests that the arbitrary 24 hour duration of symptoms as a diagnostic indicator is largely unhelpful as the MRI is the gold standard and studies show that Diffuse weighted MR has confirmed strokes in patients who's symptoms resolved in less than 24 hours and has ruled stroke out in patients who continue to have symptoms greater than 24 hours.  AS such, the 24 hour rule has been some what debunked and reduced to the category of a "90s era criteria".  Be that as it may, it is still some what of a yard stick/ litmus test for ruling in our out CVA.  

Coding guideline A.19 states that if an MD states a condition exists, his documentation is enough and we are not to censor diagnoses based on clinical criteria.  

Remember however, the UHDDS requires demonstration of evaluation, or treatment, or diagnostic tests, or extra nursing services or extended length of stay etc.

Unfortunately for a mild stroke, the treatment is pretty much some underlying medical regimen changes, PT, observation and DS home which is exactly what you are doing.

Numbness can certainly be the only signs of a mild CVA in some instances.  CT's are known to be negative in mild strokes (especially after such a short duration) and carotids are not always severely diseased in every stroke patient. 

Do you have an MD advisor handy?