coding challenges in an rpps environment

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Transcript coding challenges in an rpps environment

Lisa Bazemore, MBA, MS, CCC-SLP
• Identify common problems encountered with coding
• Share best coding practices
• Discuss implementation of a verification system
Correct Coding
• Why Correct Coding is Important
Assignment of appropriate case mix group (CMG)
Correct payment tier for co-morbidities
Prevention of issues with potential Medicare compliance audits
Compliance with the “75%” rule
Accurately coding documented diagnoses allows for appropriate
reimbursement and permits us to capture all possible resources
for our patients’ care.
Correct Coding
• Assignment of Rehab Impairment Code
 Assign the group that best describes the primary condition requiring
admission to the rehabilitation program.
 Code this according to the instructions found in the IRF-PAI Coding
Manual to insure appropriate Case Mix Group assignment (where
 RIC-Is the RIC on Appendix B as one that will stand alone for 75%
rule compliance?
• If not, look at the acute care documentation to determine what the
patient is being treated for.
• Is there an etiologic diagnosis that will qualify the patient?
Coding Multiple Impairment
• Patient with Guillain-Barre Syndrome and fractured hip, the
latter resulting from a mishap in the hospital
 Impairment group code is
• 03.4 – Guillain-Barre Syndrome
 Fractured hip is reported as a co-morbid condition.
 Note: Use of 3.4-Guillain-Barre Syndrome can be supported
by ICD-9-CM code of 357.0-Acute Infective Polyneuritis
Coding Multiple Impairment
• Patient admitted for right THR; has history of four-month
old CVA previously treated in an IRF. Still has residual
left hemiparesis requiring ongoing physical and
occupational therapy
 Impairment group code is . . . .
• 08.51 – Hip replacement
 Old CVA is reported as a co-morbid condition with a code for
late effects of CVA employed.
Correct Coding
• Best Practice
 Physician clearly identifies the rehabilitation diagnosis /
impairment group code in the History and Physical.
Etiologic Diagnosis
• Etiologic diagnosis
 Diagnosis that led to condition for which the patient is
receiving rehabilitation
 May use code for an acute condition causing the impairment
 May use code for a late effect of an acute condition if a
rehabilitation program was completed previously for same
 Some V-codes are permitted, but best to avoid them in
etiologic field
Etiologic Diagnosis
• Examples of acute conditions
 432.9 - Unspecified intracranial hemorrhage
 820.21 - Intertrochanteric hip fracture
 349.82 - Toxic encephalopathy
Late Effect Etiologic Code
• Patient completed an inpatient rehabilitation program for
a CVA six months ago and now:
 She was living alone and still had a mild hemiparesis on the
right side when she developed pneumonia.
 She just ended treatment for that pneumonia, and, because
the condition also led to increased paresis and spasticity on
the right side, she is having difficulties performing routine
activities without additional assistance.
 She is being readmitted to a rehabilitation program to again
increase independence in ADLs and in ambulation.
Late Effect Etiologic Code
From previous slide:
 Impairment group code is 01.2 – CVA with right sided
 Etiologic diagnosis – 438.21 – Hemiparesis dominant
side due to old CVA
 Note that this patient should be coded in another group if
there was no evidence and documentation of increasing
hemiparesis and spasticity that affected function.
 Physician documentation must strongly support the IGC of
Etiologic Codes
• Physician Documentation Tips
Remind physicians to be as specific as possible when
documenting. If the patient has multiple fractures, ask
them to document as follows: “Patient has multiple
fractures of tibia, sternum, and wrist.”
Where spinal stenosis is the etiologic diagnosis, the doctor
needs to clearly state what the patient will be treated
for…paresis, myopathy, general weakness.
Patients with polyneuropathy are still considered “good
rehab candidates.” The physician’s documentation should
clearly state the basis of the neuropathy.
1. Review the list of etiologic diagnoses that stand alone to
classify a patient in the 75% category.
2. Note: ICD-9 code for Diabetic Neuropathy is not present on
Appendix A of the 75% rule transmittals, but neuropathies with
a neurological basis are.
• Co-morbid condition
 Patient condition other than the impairment or etiologic diagnosis
 Exists at the time of admission/may develop during stay
 Affects treatment received and/or LOS
• Co-morbid conditions should be reported if they require:
Clinical assessment,
Additional diagnostic procedures
Therapeutic treatment
Extension of LOS,
Enhanced nursing care and/or monitoring
• List on IRF-PAI even if not in payment tier.
• Note: “Active” co-morbid conditions are those reported on the
• Complications are medical conditions
 Not present at time of admission to rehabilitation
 Identified during rehabilitation stay
 That slow or compromise the rehabilitation program
Coding Complications
• Conditions occurring prior to the day before discharge
 Record in #47 of the IRF-PAI as well as #24 of IRF-PAI
• If not recorded in #24, no potential for additional
• Conditions occurring day prior to discharge or on day of
 Do not record on IRF-PAI
 Do record on the UB-92 form
Coding Complications for
Interrupted Stays
• When complication identified on day before or day of
 Code #46 – Diagnosis for Interruption or Death – on IRF-PAI
 Item #46 to be completed on final version of PAI
• If complication still requires care after re-admission to
 Code on IRF-PAI in areas #24 – Comorbidities and #47 Complications
Coding Points to Remember
• When in question, distinguish between obesity and morbid
 Involve dietitian
 Definitions: BMI index; Dorland’s Medical Dictionary definition;
• Physician delineation of manifestations of diabetes mellitus
assists coders
 Peripheral neuropathy
 Nephropathy
 Retinopathy, etc.
Coding Points to Remember
• Employ codes in “official” list when possible
 Eg: Patient with GI hemorrhage due to duodenal ulcer
• 578.9 – GI hemorrhage
No resulting additional payment
• 532.40 – Duodenal ulcer with hemorrhage
Tier 3 co-morbidity payment
 Dialysis patients
• Use of V45.1-Renal dialysis status
Tier 1 co-morbidity payment
Key Points to Remember
Specific Impairment Groups
Impairment Group #01 - Stroke
• Indicates problem of vascular origin
• Patients with new CVA and history of “old” CVA on
opposite side that requires ongoing treatment
 Impairment group code should be 01.3-bilateral involvement
(note that both sides require medical treatment)
 Old CVA listed as a comorbidity (late effect of . . .)
 Most recent CVA accounted for in the etiologic diagnosis
 Note: Physician and team documentation must support the
fact that both sides of the body require treatment.
Impairment Group #01 - Stroke
• Now recommended that for all CVAs with dysphagia that
dysphagia be listed as comorbidity
• Iatrogenic stroke to be recorded as impairment group
and not as complication, as in case of CVA after CABG
 Impairment group – 01.2 – Stroke with right body
 Etiologic diagnosis – 434.91 – Cerebral artery occlusion with
 Comorbidities - V45.81 – Aortocoronary bypass status
- 787.2 - Dysphagia
Impairment Group #02 –
Brain Dysfunction
• Brain dysfunction – Non-traumatic
 Injury to brain/neural tissue not resulting from trauma, as
• Mass occupying lesions (eg: tumors, cysts)
If lesion excised due to craniotomy, code patient in nontraumatic brain dysfunction group
• Infectious processes (eg: meningitis)
• Metabolic disorders (eg: secondary to poisonings,
global anoxia/hypoxia)
• Structural disorders (eg: secondary to hydrocephalus)
Impairment Group #02 –
Brain Dysfunction
• Brain dysfunction – Traumatic
 Open injury vs. closed injury
 If additional injuries are present, then the patient might be
assigned to the major multiple trauma group
 With assignment to MMT group, do not unbundle injuries
and assign to IGC #2
Impairment Group #03 – Neurological
• Includes neurologic dysfunctions and neuromuscular
dysfunctions of various etiologies
 Examples are:
• Multiple Sclerosis
• Parkinsonism
• Polyneuropathy
• Myasthenia Gravis
• Myopathy (Does not include myopathy without
neuromuscular etiology eg: rhabdomyopathy)
Physician Documentation Highlights
• These are examples of neurological disorders that count
as a 75% admission
Idiopathic Progressive Polyneuropathy
Postherpetic Polyneuropathy
Polyneuropathy in collagen vasculary disease
Polyneuropathy in malignant disease
Polyneuropathy in other diseases
Alcoholic polyneuropathy
Hereditary Peripheral Neuropathy (due to ……)
Paralysis Agitans
Syphilitic Parkinsons
Secondary Parkinsons
Physician Documentation Highlights
• These are examples of neurological disorders that count
as a 75% admission
Spinal Muscle Atrophy
Peroneal Muscular Atrophy
Other Myopathies
Toxic Myopathy
Critical illness Myopathy
Myopathy in endocrine diseases
Symptomatic inflammatory myopathy in diseases classified
Impairment Group #04 –
Spinal Cord Dysfunction
• Spinal cord injury – Non-traumatic
 Structural cause - examples: syringomyelia, disc
dissection/herniation with myelopathy, vertebral
compression fractures with myelopathy
 Masses - examples: cysts, mass due to metastatic CA,
 Infectious cause – examples: abcess, HIV/AIDS
 Autoimmune disease – example: transverse myelitis
 Vascular disease – example: A-V malformation, “stroke” of
spinal cord
Spinal Cord Dysfunction
• To be classified as non-traumatic SCI, patient must have
documented continued significant lower extremity dysfunction.
• The physician should also record activity limitations due to this
dysfunction such as how overall function is affected by lower
extremity dysfunction.
Impairment Group #04 –
Spinal Cord Dysfunction
• Spinal cord injury – Traumatic
 Distinction of complete vs. incomplete injury must be made
 If there are additional injuries, consider assignment to major
multiple trauma group
• If it can be assigned to major multiple trauma category,
do not unbundle and assign to IGC #4
Impairment Group #04 –
Spinal Cord Dysfunction
 When spinal cord dysfunction patients are readmitted for a new condition, the case can be
coded again as spinal cord dysfunction ONLY IF it
is documented that the new condition is
intimately related to the spinal cord dysfunction.
Impairment Group #05 –
Amputation of Limb
• If current amputation is of L/E and there was prior
amputation of other L/E, report impairment group
code as “bilateral.”
• Note: When patients with amputation are re-admitted for a
new condition, the case can be coded again as “amputation of
limb” ONLY IF it is documented that the new condition is
intimately related to the amputation.
Impairment Group #05 –
Amputation of Limb
• If more than one condition led to the impairment,
etiologic diagnosis should be that “most proximal” to the
 Example: Patient with B/K amputation of left leg due to DM
with PVD and gangrene
• Impairment group = 05.4 – Unilateral lower limb, B/K
• Etiologic diagnosis = 785.4 – Gangrene
• Comorbidities = 250.70 – Diabetes mellitus
with peripheral vascular disease; 443.81 – Peripheral
angiopathy in diseases classified elsewhere
Impairment Group #06 – Arthritis
 Group IS NOT used when patients are admitted for
joint replacements, even if the procedures were
performed with multiple joint or generalized arthritis
also a concern
 Physician should document the type of arthritis (OA vs.
RA vs. other type of arthritis)
 With diagnoses such as “polymyositis”,
“dermatomyositis”, or “systemic lupus erythematosus”,
where arthritic involvement is to be treated and is
documented, employ impairment group
Impairment Group #07 –
Pain Syndromes
• Use when primary reason for admission is treatment of
 Do not use this impairment group if there are neurologic
deficits; instead, use (03) Neurologic Conditions or (04)
Spinal Cord Dysfunction
 Ensure that you have good documentation that the pain is a
focus of treatment. For example: adjustment of pain
medication, use of modalities by therapy, etc.
Impairment Group #08 – Orthopedic
• Group includes coding for joint replacement and postfracture of bone
 If patient fractures hip and then has THR, impairment code
to indicate hip fracture
• “V” codes are used here under comorbidity section, to
indicate joint replacement has occurred
• Group includes major multiple fractures
and “other orthopedic” conditions
 “Major multiple fractures” goes to MMT-NBSCI RIC.
What is a Major Multiple Fracture?
• 8.4-Not considered by itself an IGC permitting for 75%
categorization of patient
 Must have presence of at least two fractures that have
impacted weight bearing ability or ADL function
 Cannot use group if patient has two fractures in same bone
Impairment Group #09 – Cardiac
• Group used where major disorder is poor activity
tolerance due to cardiac insufficiency or general
deconditioning due to a cardiac condition
 Condition could be chronic or acute
Impairment Group #10 – Pulmonary
• Group used for cases where major issue is poor activity
tolerance secondary to pulmonary insufficiency
 Group use primarily intended for chronic conditions
 Generally not used for acute conditions such as pneumonia
or exacerbation of asthma
• Should use group for acute conditions only if physician
documents considerable resources being employed for
care of acute problem
Impairment Group #11 – Burns
• Involves thermal injury to areas of the skin and/or
underlying tissue
 Aside from code for burn, include code for amount of body
surface involved
• Code for body surface – 948.xx
Impairment Group #12 –
Congenital Deformities
• Group used for cases where major disorder is an anomaly
or deformity of the nervous or musculoskeletal system
present since birth
 Example: Spina bifida
Impairment Group #13 –
Other Disabling Impairments
• This group employed as a “last resort”
• Often patients placed in this group should be “debility”
Impairment Group #14 –
Major Multiple Trauma
• If fractures are one of the impairments noted, must
have at least two fracture sites (not related to skull or
spinal cord fractures) for assignment to group as major
multiple fractures plus trauma
 To assign to group with fractures present, should have
another site involved as well
• If patient with TBI or SCI and one fracture site,
impairment group code should be assigned to #02 (TBI)
or #04 (SCI) (or even the fracture as appropriate)
Impairment Group #15 –
Developmental Delay
• Group is employed for impaired cognitive or motor
function expressed as developmental delay
Impairment Group #16 – Debility
 Group assigned where there is generalized
weakness/deconditioning, often secondary to illness or
• Deconditioning cannot be attributed to other
impairment groups
 Group often used when patient admitted for increasing
strength and/or endurance
 If reason for admission is to supply some degree of therapy
along with extensive medical care, appropriate group
assignment may be Group #17
Impairment Group #16 – Debility
• Do not use group assignment if patient has a chronic
pulmonary or any cardiac condition
 For these cases, a code in Group #9 or #10 would be
• Etiologic diagnosis is disease or injury leading to the
Impairment Group #17 –
Medically Complex Conditions
• Group chosen ONLY IF reason for admission is primarily
medical treatment and rehabilitation (therapy)
programming is secondary in importance
 Constitutes nationally a VERY small percentage of patients in
acute rehabilitation units
• Patients admitted to hospital with major medical issues
and transferred to rehabilitation program for
strengthening or endurance work should be considered
appropriate for Group #16-Debility
Coding Best Practices
Coding – Best Practices
• Pre-Admission Screening: Include all diagnoses, comorbidities, and Rehab Impairment Code (RIC);
• Physician clearly identifies the RIC, Etiologic Diagnosis, and
co-morbidities in the History and Physical and Discharge
• Communicate with Coders about what you are finding
 Recommendation: The Coders come to the floor post-admission to
gather information from the H&P and Pre-Admission Screen.
• IRF-PAI Worksheet is coded using the H&P, Pre-Admission
Screen, and Coders Attestation
• IRF-PAI Verification Process
Best Practice – Concurrent Coding
• For On-Site Coders: Coder comes up to the unit every
three days and reviews the charts for accuracy in coding /
• For Off-Site Coders: information for coding is faxed /
emailed / electronically transmitted (by a designated
person) to the coder upon admission, and as patient’s
condition changes. If the coder has access to the hospital’s
electronic documentation, the coder is to review each
Rehab Chart daily for changes in the patient’s condition.
• The coder’s selected codes should be reviewed at least
weekly by a designated person on the rehab unit.
ICD-9-CM Coding Guidelines:
Variances Between the UB-92
and the IRF-PAI Forms
ICD-9-CM Coding Guidelines
• Established by the Cooperating Parties
 American Health Information Management Association
 American Hospital Association (AHA)
 Centers for Medicare and Medicaid Services (CMS)
 National Center for Health Statistics (NCHS)
UB-92 Coding Information
• The “Principal Diagnosis”
 Condition established, after study, to be chiefly responsible for
the admission
• For admission to rehabilitation, code should be V57.xx
• “Suspected”, “possible”, “probable”, etc. diagnoses not
• Conditions treated before IRF admission are reported as
“late effect” codes or not reported at all if no longer a
• Complications occurring day of discharge or day before
discharge are coded
ICD-9-CM Diagnosis Codes:
Comparison of UB-92 and IRF-PAI
• Principal diagnosis
• Etiologic diagnosis
• Secondary diagnoses
• Comorbid conditions
 Comorbid conditions
 Complications
 Other diagnoses having
effect on LOS or
Comparison of IRF-PAI for TBI Patient
• Impairment group
 02.2-Traumatic, closed brain injury
• Etiologic diagnosis
 852.4 – Extradural hemorrhage following injury, without
mention of open intracranial wound
• Co-morbid conditions
 310.1 – Cognitive deficit caused by head trauma
Coding UB-92 for Same TBI Patient
• Principal diagnosis
 V57.89 – Admission for rehabilitation
• Other diagnoses
 310.1 – Cognitive deficits following head trauma
 907.0 – Late effects of intracranial injury without mention of
skull fracture
Lisa Bazemore
[email protected]
(202) 588-1766