May 2, 2011

ICD-10-CM: Presenting Challenges and Opportunities for Inpatient Rehabilitation Facilities


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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