Rehabilitation

Rehabilitation (3)

ICD-9-CM provides codes for hemiparesis without further specification (342.0x-342.9x) and hemiparesis as a late effect of cerebrovascular disease (438.20-438.22).

Fifth digits specify the side of the body affected by the hemiplegia/hemiparesis, but guidance for assignment of the fifth digit, which also indicates the dominant/non-dominant side of the body, is not provided by the Official ICD-9-CM Coding Guidelines. The coder generally reviews the health record for documentation identifying the dominant side of the body or looks for documentation indicating whether the patient is left- or right-handed.

The ICD-10-CM Official Guidelines for Coding and Reporting 2011, Guideline I.C.6.a, however, does provide direction on assignment of codes for the side of the body affected by hemiplegia/hemiparesis and monoplegia of the upper and lower limbs.

When the affected side is specified but documentation does not indicate if it is the dominant or non-dominant side, and a default code is not included in the classification, the following guidelines should be followed:

    • When the left side is affected, the default is non-dominant.
    • When the right side is affected, the default is dominant.

This guideline also states that, for patients that are ambidextrous, the default should be dominant.

 


 

Examples:

For patients transferred to an inpatient rehabilitation facility (IRF) following initial treatment of a traumatic brain injury, an ICD-10-CM code from the S06 category is reported with a seventh character of “S” to indicate that the admission is for treatment of the sequela and not the initial treatment for the injury.

The following table shows the ICD-9-CM and ICD-10-CM codes that would be assigned when hemiplegia is the residual condition that requires rehabilitation.

Scenario

ICD-10-CM

ICD-9-CM

Traumatic brain injury with left-sided hemiplegia

G81.94 Hemiplegia, unspecified, affecting left non-dominant side

342.90 Hemiplegia, unspecified, affecting unspecified side

Traumatic brain injury suffered by left-handed patient with left-sided hemiplegia

G81.92 Hemiplegia, unspecified, affecting left dominant side

342.91 Hemiplegia, unspecified, affecting dominant side

Traumatic brain injury suffered by right-handed patient with right-sided hemiplegia

G81.91 Hemiplegia, unspecified, affecting right dominant side

342.91 Hemiplegia, unspecified, affecting dominant side

Traumatic brain injury suffered by left-handed patient with right-sided hemiplegia

G81.93 Hemiplegia, unspecified affecting right non-dominant side

342.92 Hemiplegia, unspecified affecting non-dominant side

Traumatic brain injury with hemiplegia

G81.90 Hemiplegia, unspecified, affecting unspecified side

342.90 Hemiplegia, unspecified affecting unspecified side

 

Physicians do not always include documentation that identifies the dominant side of the body. One solution to this problem is to assign responsibility for documenting the patient’s dominant hand by including a field for recording this information in the physical therapy, occupational therapy or nursing initial evaluations.

If coders currently are not reporting codes for the specific side of the body involved, they may require education on how to determine the dominant side and where to find indicators in the documentation.

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. Pat facilitates the AHIMA Coding Physical Medicine Rehabilitation Community of Practice (COP).

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When coders for inpatient rehabilitation facilities were instructed to use a code from the V57.xx series to indicate principal diagnosis, there was a loud howl of protest from those who felt that these codes did not represent diagnoses but rather the treatment a patient would receive.

It was inconsistent, as staff did not report a code to admit for medical care or a code to admit for surgery. However, this was an efficient method through which to group a patient to DRG 462 for rehabilitation. Rehabilitation facilities excluded from the DRG payment methodology also were instructed to use this code to indicate principal diagnosis.

The 2002 implementation of the IRF PPS included completion of the Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF PAI). The IRF PAI required code assignment for the etiology, comorbid conditions, complications and reasons for interrupted stays or death.    The IRF PAI instructions for code assignment mandated the etiology-advised coders to report the diagnostic code for the acute condition that was responsible for the impairment. This was unusual, and ran contrary to how the official guidelines instructed coders to operate.

Once again, coders had to accept change, although they did not understand why code V57.89 couldn’t be reported as the etiology, as it was appropriate for the billing form. The response to this was that the billing form and the IRF PAI are separate documents. The IRF PAI is a separate data set, meaning the Official ICD-9-CM Guidelines for Coding and Reporting do not apply to code assignment for it.

Then Came MS DRGs

With the introduction of Medicare Severity – Diagnostic Related Groups (MS –DRGs), the rehabilitation DRGs changed to DRG 946, rehabilitation with major complication/comorbidity (MCC), and DRG 945, Rehabilitation without CC or MCC.

ICD-9-CM codes for the principal diagnoses that assign DRGs 945 or 946 include:

V52.8            Fitting and adjustment of other specified prosthetic device

V52.9    Fitting and adjustment of unspecified prosthetic device

V57.1    Other physical therapy

V57.2            Occupational therapy and vocational rehabilitation

V57.3    Care involving use of rehabilitation speech-language therapy

V57.89 Other specified rehabilitation procedure

V57.9            Unspecified rehabilitation procedure

 

It is possible to map codes V52.8 and V52.9 to ICD-10-CM codes in the Z44 series of codes. These codes seldom are used as a principal diagnosis by inpatient rehabilitation facilities.

The official ICD-9-CM coding guidelines indicate that only one code from the V57 series of codes should be reported. Inpatient rehabilitation facilities report code V57.89 for inpatient admissions to indicate that a patient will receive therapy in multiple therapy disciplines.

Mapping Won’t Get You There

A simple mapping of the V57 series of codes found in ICD-9-CM over to ICD-10-CM is not possible, as codes that duplicate the V57 series currently are not included in ICD-10-CM classification.  Inpatient rehabilitation coders will need to be flexible, as change is inevitable. How to assign the inpatient rehabilitation DRGs when ICD-10-CM is implemented is a matter still being studied.

One possible solution for assignment of the rehabilitation DRGs is to add additional codes to the ICD-10-CM classification, replacing the current V codes used for ICD-9-CM. Another possible solution would be to map to the rehabilitation DRGs the ICD-10-PCS procedure codes for Physical Rehabilitation and Diagnostic Audiology, F00-F15.

A solution will need to be found prior to Oct. 1, 2013.

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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The ICD-9-CM classification system does not always provide codes allowing an Inpatient Rehabilitation Facility (IRF) to report the root condition that required admission. ICD-10, with its increased number of codes, will allow IRFs to collect additional details about the reasons for admission. However, in order to assign these more detailed codes, physicians will need to improve the quality of their documentation.

In 1979, when ICD-9-CM was implemented, there were no official guidelines for the assignment of codes by IRFs. Codes reported for principal diagnoses were inconsistent. The following example shows how different facilities would report the principal diagnosis:

The patient was admitted to the IRF for rehabilitation following a transverse fracture of the femur shaft that was treated at the acute-care facility via open reduction and internal fixation.   The codes that facilities once would assign for the principal diagnosis included:

821.01.                Fracture shaft of femur

905.4                   Late effect of fracture of lower extremities

719.7                   Difficulty walking

Since 1979, guidelines have been developed for IRFs reporting codes. The Official ICD-9-CM Guidelines for Coding and Reporting advises that code V57.89 should always be assigned as the principal diagnosis when a patient is admitted for rehabilitation, with additional codes added to indicate the conditions that required rehabilitation. If the above patient was admitted to an IRF today, the case would be coded as follows:

V57.89                Admission for other specified rehabilitation procedure

V54.15                Aftercare for healing traumatic fracture of upper leg

Detailed information is not always required to assign ICD-9-CM codes, as codes that report aftercare do not include detail. Enhanced documentation including additional details will be required to assign ICD-10 codes. For the above case, the coder would need additional information about laterality, the site of the fracture and whether the fracture is open or closed, displaced or non-displaced. In ICD-10 a fracture not specified as displaced or non-displaced should be coded as displaced, and a fracture not specified as open or closed should be coded as closed. In this case neither was specified, so codes indicating a closed, displaced fracture should be reported. A seventh digit is required to show this type of encounter. Remember, the patient was admitted following fracture treatment at the acute-care facility, so a code that indicates a subsequent encounter should be selected.

For code S72.321 there are 16 options listed for the seventh digit. The options require that documentation indicates whether the encounter is for:

  • The initial or subsequent treatment of the fracture or for the sequela;
  • An open or closed fracture and, if open, the type of open fracture; or
  • Routine healing, delayed healing, non-union or malunion.

The possible seventh digits include:

A.      Initial encounter for closed fracture

B.      Initial encounter for open fracture, type I or II (open NOS or not otherwise specified)

C.      Initial encounter for open fracture, type IIIA, IIIB, or IIIC

D.      Subsequent encounter for fracture with routine healing

E.      Subsequent encounter for open fracture, type I or II with routine healing

F.      Subsequent encounter for open fracture, type IIIA, IIIB or III C with routine healing

G.      Subsequent encounter for fracture with delayed healing

H.      Subsequent encounter for open fracture, type I or II with delayed healing

J.       Subsequent encounter for open fracture, type IIIA, IIIB or III C with delayed healing

K.      Subsequent encounter for fracture with nonunion

M.     Subsequent encounter for open fracture, type I or II with nonunion

N.      Subsequent encounter for open fracture, type IIIA, IIIB or III C with nonunion

P.      Subsequent encounter for fracture with malunion

Q.      Subsequent encounter for open fracture, type I or II with malunion

R.      Subsequent encounter for open fracture, type IIIA, IIIB, IIIC with malunion

S.      Sequela

So the ICD-10 code assignment for this fracture is:

S72.321D Subsequent encounter for displaced transverse fracture of shaft of right femur with routine healing

The physician did not specify whether the fracture was displaced or non-displaced, so a code for displaced was assigned. The above example illustrates the need for detailed documentation by the physician. It currently is not uncommon for physicians to document the admission diagnosis as status post-femur fracture without including any additional information about the fracture. Physicians will require education on the need to document the required information for assignment of the seventh digit.

Now is the time to start educating physicians about the documentation that will be required for accurate ICD-10 code assignment for those diagnoses that are treated often at your rehabilitation facility.

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.  She was responsible for the initial start-up of HIM departments at three large acute medical rehabilitation hospitals where she designed, developed and implemented policies and processes. She was part of the 11-member task force that developed the Functional Independence Measure (FIMTM) and the minimum data set for the Uniform Data System for Medical Rehabilitation (UDSMR), an integral part of Medicare’s prospective payment system for inpatient rehabilitation facilities (IRFs). 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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