Updated on: November 28, 2016

Not Taught in Med School, Mystery Code Analyzed

Original story posted on: January 11, 2016

After all this time, functional quadriplegia is still a dysfunctional medical diagnosis. Around this time in 2008, the Patriots’ perfect season was soon to be ended by the Giants in Super Bowl XLII, and Patrick Swayze would be diagnosed with pancreatic cancer. By the end of the year we would have a new president named Barack Obama.


We would also have a new code for a diagnosis not taught in medical schools and not addressed as an illness by the medical establishment.

In 2016, we long ago said goodbye to Patrick and are gearing up once again for a presidential election, but we still have not yet figured out what it means for a patient to be functionally quadriplegic.

When the new code was created on Oct. 1, 2008, the accompanying Coding Clinic clearly defined functional quadriplegia as a condition not related to a true paresis. This fact is usually my opening line when I am discussing the diagnosis with a physician. The disclaimer also includes admitting that it is not a clinical diagnosis, nor something that is taught in medical school. That tells us what it isn’t, but not very much about what it is.

Think of functional quadriplegia as a synonym for “total care.” If we are perfectly honest, we have to admit that the term chosen to capture this scenario is unfortunate in itself. It is confusing at face value because the term will have you looking for a patient who is completely paralyzed in all four limbs, which is not really the defining criteria of the diagnosis. 

Coding Clinic goes on to define functional quadriplegia as the inability to move due to another condition (such as dementia, severe contractures, arthritis, etc.). Musculoskeletal disorders such as arthritis causing a severe immobility clearly refute the argument that the condition must include a paralysis component. The next line indicates that a neurological or mental condition may create the immobility, and it cites dementia as the most likely and frequently cited cause. Last but not least, the condition is defined as a simple frailty or disability, which could include an almost unlimited number of possible causes.

A problematic passage in the Official Coding Guidelines creates additional misconceptions. In an attempt to make clear that this is not the code for a patient with a true spinal lesion, the guidelines indicate that the diagnosis of functional quadriplegia is not associated with neurologic deficit or injury. The reason this line is problematic is that it is simply wrong. Alzheimer’s dementia, the most common precipitating clinical scenario leading to a valid functional quadriplegia diagnosis (according to Coding Clinic), is clearly a neurological problem. Contractures, which are also listed in Coding Clinic as a valid justification for a diagnosis of functional quadriplegia, frequently have their pathophysiological basis as an underlying neurological disorder. Neurological disorders such as multiple sclerosis, amyotrophic lateral sclerosis (ALS), stroke, spina bifida, Huntington’s, etc. all produce patients that are “frail or disabled,” meeting they suffer from Centers for Medicare & Medicaid Services (CMS)-approved criteria as an underlying disease process leading to a patient who is functionally quadriplegic.

To put it simply, whoever wrote that line of the official guidelines oversimplified their point in an attempt to dissuade people from using the diagnosis with a spinal lesion. Unfortunately, the passage has made its way into the ICD-10 guidelines as well. In reality, I do not believe the official guidelines were ever meant to contradict Coding Clinic guidance. It was simply worded in an unfortunate manner, allowing it to be easily misinterpreted.

It is noteworthy that there is a hierarchy of advice that helps us out. The hierarchy goes: a) ICD-10 instructional notes and index, b) Coding Clinic, c) Official Guidelines. ICD-10 instructional notes supersede all other guidance, and ICD-10 code R53.2 is not an excludes 1 code for stroke, MS, ALS, Parkinson’s, Alzheimer’s, cerebral palsy, etc. Per ICD-10 guidelines, any code not specified as an excludes 1 may be appropriate to assign as an additional diagnosis. Furthermore, the Coding Clinic defining the diagnosis as that which can occur along with neurological conditions (dementia), musculoskeletal conditions, or even severe frailty supersedes the guidelines inferring that neurological conditions are off-limits. 

“Functional” is also more problematic than it should be. While physicians are accustomed to diagnoses of functional vomiting or diarrhea (GI dysfunction without an identifiable pathology) and functional uterine bleeding (as opposed to dysfunctional uterine bleeding), a functional neurological disorder is foreign. Typically, neurological disorders aren’t functional in nature; they may be psychiatric or physiologic, but there is no such thing as a functional stroke or a functional neuropathy. 

Clinical documentation specialists (CDSs) should work to redefine the meaning of functional quadriplegia for physicians as simply a classification for a patient who is completely dependent as it pertains to their activities of daily living. Again, it is not true paresis that begs the question; why even bother reporting it? In general, it will not meet the treatment criteria, nor does it require evaluation and management by the physician. What listing functional quadriplegia does is capture the added severity as it relates to increased nursing care, longer lengths of stay, and higher costs associated with caring for that patient. More importantly, it is a huge risk adjuster. The data contained in the diagnosis of functional quadriplegia is a top mechanism to account for the expected higher risk of mortality, risk of readmission, higher costs of care, and increased complication rates in a patient population that is unable to feed, bathe, ambulate, or use the restroom independently. Ironically, healthcare quality initiatives impacting this area were not a common topic of discussion in 2008, but are of paramount importance in 2016.

If you have patients that can feed themselves, then don’t query for functional quadriplegia. Likewise, if they are only a “one assist” to the chair and are able to groom themselves or ambulate with assistance, the diagnosis is unsupported. On the other hand, if you have a patient who has to be fed, bathed, helped to the restroom, and requires a lift chair or two-person assist, you absolutely should be capturing the documentation of functional quadriplegia. Inability to ambulate and/or transient and severe weakness are not defining criteria, while long-term severe weakness and frailty potentially could be.

Examples I have not yet mentioned could include patients in a coma or patients suffering from a persistent vegetative state, traumatic brain injury, multiple amputations, or severe burns. LTAC patients suffering from degenerative demyelination disorders or hypoxic or congenital neurological deficits absolutely should be evaluated to see if they meet the total care threshold for this diagnosis. Don’t assign this diagnosis to patients whose total dependency is transient or medically induced, such as those in a chemically induced coma or on ventilation. While I don’t generally recommend that the status be permanent to qualify for this diagnosis, it must be long-term and/or associated with a patient who requires total care for the majority if not all of the inpatient or LTAC admission being coded.

Obtaining the clinical indicators for this diagnosis should be aided by physical therapy, occupational therapy, or nursing care notes supporting the patient as being dependent for all of their ADLS. Caution is warranted in validating this information. What is written as “total care” by nursing staff may not meet the criteria of requiring the care described by the diagnosis of functional quadriplegia. Be clear that the patient has to be fed or is on TPN/feeding tube, has to have their restroom needs cared for, or has a Foley/colostomy/ileostomy and requires mobility beyond just receiving assistance to a walker or chair.

While the criteria I am suggesting here may eliminate some borderline patients (and I say, rightfully so), it also gives us a defining criteria that is defensible to a resistant medical staff as well as a Recovery Auditor (RA) or insurance auditor. 


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.
Allen R. Frady, RN, BSN, CCS, CCDS, AHIMA Approved ICD-10-CM/PCS Trainer

With 20 years in healthcare, Allen R. Frady provides clients assistance in the areas of documentation, program implementation and compliance. His background includes critical care nursing, coding, auditing, utilization review, and documentation improvement.

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