February 22, 2016

Far Reaching Impact of Functional Quadriplegia

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Functional quadriplegia (R53.2) is defined as “the inability to move due to severe disability or frailty caused by another condition without physical injury or damage to the brain or spinal cord,” describes Richard Pinson, MD. This oft-overlooked secondary diagnosis may have significant impact on the final MS-DRG, relative weight, length of stay (LOS), severity of illness (SOI), and risk of mortality/morbidity (ROM) of any case, as it is a major complication/comorbidity (MCC).

The ICD-10 Official Guidelines for Coding and Reporting defines the condition as the “lack of ability to use one’s limbs or to ambulate due to extreme debility. It is not associated with neurologic deficit or injury and should not be coded in cases of neurological quadriplegia.”

Would you overlook capturing quadriplegia due to spinal injury or trauma? Of course not. Is the patient noted to be bedbound? Nurses know that this condition requires more nursing time and effort for completing patient care and assisting the patient with their activities of daily living. Physical and occupational therapy, and possibly even speech therapy, would be included in this patient’s care.

Potential causes could be related to dementia, multiple sclerosis, amyotrophic lateral sclerosis (ALS), severe intellectual disability, advanced crippling arthritis, and several others. So, consider the patient’s past medical history. Look at the nursing documentation for Braden Scale, with a focus on mobility (1 = complete immobility and 2 = very limited mobility) and activity (bedfast/chairfast) scores. Read the physical and occupational therapy notes. Is the patient a total or maximum assist?

This patient population is at a greater risk of developing pressure ulcers, contractures, aspiration, nutritional support, and for requiring a Foley catheter for bladder drainage.

The physician may note phrases such as “complete” or “very limited mobility,” “bedbound-PT/OT evaluation,” or similar documentation. Nursing notes may include documentation of “total care” and additional conditions the patient may have due to the functional immobility, i.e. dementia, pressure ulcer, contractures, etc. These patients are unable to turn themselves, unable to feed or groom themselves, may have fecal and/or urinary incontinence, and exhibit a high degree of dependence.

Be sure your documented support is strong prior to placing a query. If functional quadriplegia is the only MCC, it may make the record a target for auditors. But if it is truly present, given the care these patients require, it should be coded to capture the added severity, increased ROM, higher costs of care, longer LOS, and increased complication rates.

Sample Query:

Dear Dr. Smith:

Patient presented from SNF and admitted for treatment of a UTI. The medical record indicates complete immobility/bedbound. Nursing notes contractures, stage 2 sacral pressure ulcer, and total care. Physical therapy noted max 2 assist. Wound care is following for decubitus ulcer on the sacrum. Patient is receiving Jevity via G-tube. PMH of advanced dementia and severe rheumatoid arthritis. Please indicate if one of the following accurately describes any additional diagnoses for this patient:

1)   Functional quadriplegia

2)   General debility/deconditioning

3)   Other

4)   Unable to determine

In the above scenario, the PDx is N39.0, UTI. Secondary diagnoses are F03.90, unspecified dementia without behavioral disturbance, L89.152, pressure ulcer of sacral region stage 2, and M06.9, rheumatoid arthritis. MS-DRG would be 690 (kidney and urinary tract infections without MCC), relative weight 0.7828, LOS 3.1; SOI and ROM would both be 2.

If the physician agrees with functional quadriplegia, R53.2, an MCC, would change the RW to 1.0821, LOS to 4.0, and the SOI would change to 3. ROM would not be impacted.

It should be noted that frailty (R54), hysterical paralysis (F44.4), immobility syndrome (M62.3), neurologic quadriplegia (G82.5-) and quadriplegia (G82.50) are Excludes1 Notes and are not to be coded with R53.2, functional quadriplegia.

Potential comorbid conditions to look for that may be associated with functional quadriplegia can include pressure ulcers, malnutrition, atelectasis if pulmonary hygiene is not addressed, and aspiration pneumonia, among others. Specificity of these secondary diagnoses may have further impact on the SOI and ROM.

As you can see, it is important for our physicians to be aware of the meaning of this diagnosis. Regardless of the reason for the admission, these patients likely will have an increased length of stay.

The amount of nursing time required to provide these patients with appropriate care should be accurately reflected in the coding.

Tina Ferguson, RN, CCDS

Tina Ferguson is a senior healthcare consultant for Panacea Healthcare Solutions. She has more than 11 years in clinical nursing, clinical documentation improvement and chart auditing. In her role Tina performs clinical documentation improvement audits that focus on clinical documentation improvement opportunities related to severity of illness, risk of mortality and quality. Formerly, she was a remote nurse auditor for a recovery auditor.

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