Updated on: November 21, 2016

IRFs and ICD-10: Know the Codes and Your Coders!

By Angela Phillips, PT
Original story posted on: July 13, 2015

With Oct. 1, 2015, and the final implementation date for ICD-10-CM rapidly approaching, Inpatient Rehabilitation Facilities (IRFs), like all healthcare providers, should be in the final stages of preparation and training for the changes in coding requirements.  While most IRFs have been preparing for the transition for some time, it’s never too late to do some additional review and training of staff.

Coding IRF Accounts: It’s Complex

Assigning the correct codes to an IRF account impacts the organization in a number of ways, including:

  • The calculation of presumptive compliance with the required CMS-13 diagnostic categories based on the Impairment Group Code and Etiological Diagnosis pairing;
  • Identifying potential comorbid conditions that would qualify the cases as a CMS-13 compliant case when the comorbid condition is sufficient to require care in an IRF; and
  • Identifying comorbid conditions associated with additional payments, commonly called “Tier Level Payable Conditions.”

The Changes: A Summary?

ICD-10-CM is a coding of diseases, signs and symptoms, abnormal findings, complaints, social circumstances and causes of disease or injury as classified by the World Health Organization. The code set provides a standardized methodology for capturing diseases and conditions and is expected to improve the ability to measure quality and patient outcomes because of the increased detail and granularity that is captured in the codes.

Some of the specific changes between ICD-9 and ICD-10 include:

  • An expansion in the code set from five positions to seven positions.
  • An increase of more than 13,000 codes from the prior set.
  • A significant increase in specificity of the reporting, allowing more information to be conveyed in a code.
  • Modernized terminology that has been made consistent throughout the code set.
  • Addition of codes that combine diagnoses and symptoms.
  • Enabling the reporting of laterality and hand dominance.

Key Issues for IRF Staff

Since there is a greater level of specificity required under coding guidelines—and this translates to a greater requirement for documentation of specific informationit is essential that physicians and staff include the required information in their documentation. 

While your coding staff is likely to query for missing information, it is essential that clinical staff provide sufficient information to code at a level that allows us to capture the appropriate conditions for CMS-13 diagnostic groups and for Tier level payment. Common coding principles generally require the physician to document the condition in order for the coder to “code” it. For this reason, it is essential that good communication between the attending and the clinical staff occurs throughout the patient stay.

At a very basic level, all notes related to injury, weakness, or functional loss should include information related to body part, laterality, and, as appropriate, hand dominance. Having this information allows coding professionals to apply coding principles for ICD-10.

Disease specific information is also essential. While in the past we may have coded late effects of a CVA as 438.20, under ICD-10, it will be essential to have more information related to the condition that caused the resultant hemiparesis. There are multiple sequela codes that describe hemiparesis and in order to most accurately code this condition, the coder requires the following information:

  • Condition or nature of disease or injury that caused the sequela (traumatic vs. non-traumatic subarachnoid hemorrhage, traumatic vs. non-traumatic intracranial hemorrhage, cerebral infarction, etc.)
  • Monoplegia vs. hemiplegia
  • Upper limb vs. lower limb
  • Right side vs. left side
  • Dominant vs. non-dominant

In addition to describing the condition at this level, a patient who has speech and language deficits would also have coding related to aphasia, dysphasia, dysarthria, or fluency. This needs to be clearly documented as well.

So, late effects of CVA (438.20) might soon have the following codes as well as others:

  • I69.354 Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side; and
  • I69.321 Aphasia following cerebral infarction.

Collaboration with your Coding Staff

IRF Case Managers and PPS Coordinators play a large role in assuring that documentation of the patients’ care and services is accurate and timely and these professionals can be very helpful in assuring that key elements are addressed during the patient stay. Coding of medical conditions is a complex system that has changed significantly with the updated ICD-10-CM code set and all IRFs should partner with their professional coding staff or consultants to assure that real-time audits are identifying any potential issues for the organization.

It’s a significant team effort to assure that the documentation of the required elements occurs and there is ongoing education about required documentation elements.

Failure to code correctly could result in missing cases that would qualify as CMS-13 under the presumptive methodology as well as lost revenues from failure to identify Tier Level comorbid conditions. 

Available External Resources

IRFs don’t have to go it alone! There are many resources available to assist with the transition to ICD-10, and some of the best resources are the coding professionals within your own organization. Additionally, many of the national professional organizations have tools and training available to help with the transition.

Resources every IRF should make available to their PPS Coordinators and Coding Staff include:

  • A copy of the current IRF-PAI training manual;
  • The updated list of CMS-13 qualifying diagnosis – Updated to ICD-10;
  • The updated list of Tier Level Comorbid Conditions – Updated to ICD-10  (these three documents can be downloaded from the CMS Website); and
  • Copies of the current ICD-10-CM manuals.

Final Preparation

In the final few months before full implementation, IRFs should continue to work with their physicians and staff to communicate documentation requirements and provide ongoing training related to ICD-10. There are excellent online training programs from the major IRF-PAI vendors as well as from a number of the professional organizations and these have been customized to the needs of the IRF.

For IRFs that use the top IRF-PAI software vendors: Start now looking at the updated codes in the software in preparation and utilize your vendors’ training resources to assure success with ICD-10.

About the Author

Angela M. Phillips, PT, is president & chief executive officer of Images & Associates. A graduate of the University of Pennsylvania, School of Allied Health Professions, she has more than 35 years of experience as a consultant, healthcare executive, hospital administrator, educator, and clinician. Ms. Phillips is one of the nation’s leading consultants assisting Inpatient Rehabilitation Facilities in operating effectively under the Medicare Prospective Payment System (PPS) and in addressing key issues related to compliance.

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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.

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