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By Richard Pinson, MD, FACP
Quadriplegia or quadriparesis is a very familiar condition that would never go unnoticed and undocumented in the medical record. The causes are typically catastrophic damage to the brain or upper spinal cord due to trauma, vascular injury or neoplasm.
Functional quadriplegia, on the other hand, is a bona fide clinical condition comparable to physical quadriplegia in its consequences, yet rarely diagnosed. The impact of functional quadriplegia on intensity and complexity of care, severity of illness, and cost of care is equivalent in every respect to physical quadriplegia.
Photo by Thinkstock.
Functional quadriplegia (or quadriparesis) is defined as the complete inability to move due to severe disability or frailty caused by another medical condition without physical injury or damage to the brain or spinal cord. Patients usually do not have the mental ability to move themselves and require “total care,” such as turning every one or two hours and full assistance with feeding, elimination and hygiene.
The Braden Scale, performed by nurses to predict the risk of developing pressure ulcers, has two objective indicators that are useful in identifying functional quadriplegia: mobility and activity (see sidebar).
Likewise, nursing assessments of functional quadriplegics' basic activities of daily living (ADLs) will indicate a high degree of disability or dependence on such measures as communication, ambulation, transferring, dressing, eating, swallowing, toileting and bathing.
The most common cause of functional quadriplegia is advanced neurologic degeneration from dementia, hypoxic injury, amyotrophic lateral sclerosis, Huntington's disease, multiple sclerosis or similar conditions. However, some birth defects or advanced musculoskeletal deformity (including severe, progressive arthritis) may result in functional quadriplegia.
Typical consequences or manifestations of functional quadriplegia are pressure ulcers, flexion contractures, recurrent aspiration, alimentation support including G-tube feeding, fecal incontinence, and catheter drainage of the bladder.
From a coding perspective, physical quadriplegia and functional quadriplegia are both considered major, significant, complicating or comorbid conditions that contribute substantially to the severity of illness, complexity of care and hospital reimbursement for the costs of caring for such patients. Imagine the intensity of nursing care required in these circumstances. The length of hospital stay for patients with functional quadriplegia who are admitted for any other medical problem will likely be prolonged as well. Both functional quadriplegia (complete paralysis) and functional quadriparesis (partial paralysis) are coded as the same condition.
In summary, consider and document the diagnosis of functional quadriplegia in those severely impaired patients who require “total care” or near-total care in association with advanced, debilitating medical conditions. The Braden Scale or ADLs may also provide objective evidence of functional quadriplegia. Make sure these patients are receiving appropriate supportive care consistent with quadriplegia and evaluate for additional needs related to complications of pressure ulcers, aspiration, nutritional support, hygiene and elimination.
Richard Pinson, MD, FACP, is a certified coding specialist and co-founder of HCQ Consulting in Houston. This material is adapted with permission.
Ask Dr. Pinson
Q: When a patient is admitted, the physician does a history and physical with all the probable diagnoses that are being considered as the reason for admission. When the patient is discharged, the discharge summary no longer contains the diagnoses that were first suspected on admission but were ruled out in the progress notes by the consultants. However, the patient is still coded with the admitting diagnosis. The specific case I am referring to listed the admitting diagnosis as “right-sided heart failure, chronic COPD, pulmonary hypertension.” The cardiologist (whose assessment trumps the hospitalist's working diagnosis, my coders tell me) was called in as a consult and said it was “cor pulmonale.” The diagnosis on discharge was “cor pulmonale” and there was no mention from the discharging doctor of “right-sided heart failure” in his dictation. Our coding department gave the case 428.0 as the primary diagnosis. This looks like an “upcoding” situation. Please explain the rationale if coded correctly since 428.0 is “CHF, unspecified” and in this particular case his congestion was specified as “cor pulmonale.”
A: The answers to your questions are a bit complex.
Let me begin with what diagnoses are assigned codes on the claim form. The principal diagnosis is determined by the coder using rules set forth by ICD-9-CM and the CMS Official Guidelines for Coding and Reporting based upon physician documentation in the medical record. It is defined as “that condition established after study to be chiefly responsible for occasioning the admission of the patient to the hospital for care.” That means the condition, or at least signs or symptoms of the condition, must be present on admission, but it will be the diagnosis finally determined by the time of discharge to have been the most important reason for admission.
There are lots of rules stating what can or cannot be assigned as principal diagnosis under different circumstances, which the coder must also consider. Sometimes, what seems clinically to be the appropriate diagnosis cannot be used based on one of these many rules. However, if a diagnosis is clearly “ruled out” and stated as such, it should not be coded. If a diagnosis is not specifically stated as “ruled out,” it may have to be coded because coders cannot “interpret” what has or has not been “ruled out.”
All other diagnoses or conditions present on admission or occurring after admission that are “pertinent” to the current episode of hospitalization are also coded as “other” or “secondary” diagnoses, including chronic conditions receiving treatment.
For inpatient (not outpatient) coding, possible, probable or suspected diagnoses are usually coded unless specifically “ruled out” or superseded by a more specific or confirmed diagnosis. Signs or symptoms are usually not coded when a specific diagnosis causing them is established.
The discharge summary itself is not the definitive or sole source for coding of diagnoses. The entire medical record must be reviewed to decide what conditions were present and should be assigned codes. Per CMS, only diagnoses or conditions documented by a “provider” may be used, but this includes nurse practitioners, physician assistants, residents, and others who are licensed and credentialed to treat patients and make diagnoses.
No particular clinician's documentation trumps any other. The attending physician, specialists, residents and physician assistants are all equal for documentation purposes, unless there is conflicting information. In that case, the attending physician should be queried for clarification.
Finally, if “cor pulmonale” (not specified as acute) is the principal diagnosis established after study as the reason for admission, the code assigned should be 416.9, not 428.0; acute cor pulmonale is code 415.0. If CHF is also documented, code 428.0 would also be assigned as a secondary diagnosis since coding rules require that all forms of heart failure documented in the record be coded.
Got a documentation or coding question? Dr. Pinson will respond immediately, and the question may then appear in an upcoming issue of the magazine. Please e-mail your questions.
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From the March 4, 2015 edition
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