CMS Provides Inpatient Rehabilitation Facilities/Units a Reason to Report Detailed ICD-10-CM Diagnosis Codes

Original story posted on: November 4, 2013

Codes in the ICD-10-CM code set are more detailed than the codes included in ICD-9-CM. To assign these detailed codes, physician documentation will need to include more specific and detailed information. There are ICD-10 codes for unspecified conditions, and coders have indicated they could avoid the query process and assign these unspecified codes when the physician documentation does not include the detail necessary to assign a more specific code. CMS wants coders to assign the ICD-10 codes that provide detailed information.

An IRF must meet certain criteria to be excluded from the Inpatient Prospective Payment System (IPPS) and the DRG payment methodology. One of the criteria states that 60 percent of the IRF’s total patient population must require treatment for one or more of 13 specified conditions. These conditions include:


  • stroke
  • brain injury
  • spinal cord injury
  • fracture femur (hip)
  • congenital deformity
  • major multiple trauma
  • neurologic disorders
  • burns
  • amputations
  • active polyarticular rheumatoid arthritis, psoriatric arthritis, and seronegative arthropathies
  • systemic vasculidities with joint inflammation
  • severe advanced osteoarthritis
  • knee or hip replacement immediately preceding the IRF admission and also must meet additional criteria

CMS has a computer program that reviews the codes reported on the IRF Patient Assessment Instrument (PAI) to determine if a facility is presumptively compliant with the 60 percent rule when Medicare Fee-for-Service or Medicare Advantage patients represent at least 50 percent of the facility’s patient population. If one or more codes reported on the IRF PAI for the Impairment Group, etiology or comorbid conditions are included on the list of presumptively compliant codes, the case is considered compliant and counted toward meeting the 60 percent rule.

The list of codes currently used to determine presumptive compliance was implemented October 1, 2007. This list includes codes for both specified and unspecified conditions.

CMS published the proposed rule for Federal Fiscal Year 2014 for the Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS) in May 2013 and included a surprise for the IRFs. The proposed rule included over 330 codes that would be deleted from the list of ICD-9-CM codes considered compliant with the 60 percent Rule.

The codes proposed for deletion represent unspecified diagnoses, arthritis, congenital anomaly diagnoses, unilateral upper extremity amputations, and miscellaneous diagnoses that do not require intensive rehabilitation services. CMS indicated that there were more specific codes to report the unspecified conditions. Rehabilitation facilities expressed concern over the deletion of codes for nonspecified diagnoses and for certain codes indicated that the IRF did not have the information and could not easily obtain the information to report a more detailed code.

The IRF PPS final rule for Federal FY 2014 was published in August 2013 with over 250 codes that will be deleted from the list of compliant codes; CMS retained 68 of the codes that had been proposed for deletion. The codes retained included code 434.91, cerebral artery occlusion, with infarction, and code 433.91, occlusion and stenosis of pre-cerebral artery with cerebral infarction, as it could not always be determined if the infarction was due to an embolism or a thrombus. Other codes that were retained include codes for non-specific traumatic brain injury that do not indicate if there was a loss of consciousness or the duration of a loss of consciousness, and codes that do not indicate where on the neck of the femur a fracture occurred.

The deletion of codes from the list of presumed compliant codes will make it harder for the IRF to meet the required 60 percent Rule. IRFs that do not meet the 60 percent Rule are no longer exempt from the IPPS and could be paid at the lower DRG rates.

CMS has provided IRFs with a reason to improve physician documentation so the detailed ICD-10 codes can be assigned, as reporting codes that represent unspecified conditions could result in a facility not meeting the 60 percent Rule.

To provide time for facilities to adjust to the changes and for coder education, the deletions to the list of complaint codes will not be implemented until the IRF PPS for Federal FY 2015 starts on Oct. 1, 2014. CMS has indicated that it is still reviewing the codes on the list of compliant codes and could still make additional changes before implementation on Oct. 1, 2014. Codes finalized in this rule will be used to build the ICD-10-CM version of the codes used to determine presumptive compliance.

The IRFs need to start now to improve physician documentation.

  • Review the codes assigned during the past six months to a year that represent an unspecified diagnosis
  • Review the ICD-10-CM codes for the conditions reported by the unspecified diagnosis code
  • Determine the documentation that will be required to assign a detailed ICD-10 code
  • Provide education and guidance for the physicians now, as it takes time to change documentation practices

About the Author

Patricia Trela, RHIA, is the director of HIM and rehabilitation services for Diskriter, Inc., a consulting firm offering integrated HIM rehabilitation consulting services, including HIM Interim management, IRF PPS compliance and education, coding and auditing support, dictation/transcription, and other solutions. She has more than 25 years of healthcare industry experience.  As a consultant, Pat has worked with many acute-care hospitals, rehabilitation hospitals and long-term acute-care hospitals (LTACH).  Pat facilitates the AHIMA Coding Physical Medicine Rehabilitation Community of Practice (COP).

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Disclaimer: Every reasonable effort was made to ensure the accuracy of this information at the time it was published. However, due to the nature of industry changes over time we cannot guarantee its validity after the year it was published.