CODING GUIDELINES AND BEST PRACTICES FOR INPATIENT REHABILITATION FACILITIES Lisa Bazemore, MBA, MS, CCC-SLP

1. CODING GUIDELINES AND BEST PRACTICES FOR INPATIENT REHABILITATION FACILITIESLisa Bazemore, MBA, MS, CCC-SLP

2. Objectives • Identify common problems encountered with coding • Share best coding practices • Discuss implementation of a verification system

3. 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.

4. 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 available). • 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?

5. 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

6. 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.

7. Correct Coding • Best Practice • Physician clearly identifies the rehabilitation diagnosis / impairment group code in the History and Physical.

8. 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 impairment • Some V-codes are permitted, but best to avoid them in etiologic field

9. Etiologic Diagnosis • Examples of acute conditions • 432.9 - Unspecified intracranial hemorrhage • 820.21 - Intertrochanteric hip fracture • 349.82 - Toxic encephalopathy

10. 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.

11. Late Effect Etiologic Code From previous slide: • Impairment group code is 01.2 – CVA with right sided involvement • 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 CVA.

12. 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. • Review the list of etiologic diagnoses that stand alone to classify a patient in the 75% category. • 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.

13. Co-morbidities • 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 IRF-PAI.

14. Complications • Complications are medical conditions • Not present at time of admission to rehabilitation • Identified during rehabilitation stay • That slow or compromise the rehabilitation program

15. 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 reimbursement. • Conditions occurring day prior to discharge or on day of discharge • Do not record on IRF-PAI • Do record on the UB-92 form

16. Coding Complications for Interrupted Stays • When complication identified on day before or day of interruption • 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 IRF • Code on IRF-PAI in areas #24 – Comorbidities and #47 -Complications

17. Coding Points to Remember • When in question, distinguish between obesity and morbid obesity • Involve dietitian • Definitions: BMI index; Dorland’s Medical Dictionary definition; NIH • Physician delineation of manifestations of diabetes mellitus assists coders • Peripheral neuropathy • Nephropathy • Retinopathy, etc.

18. 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

19. Key Points to Remember for Specific Impairment Groups

20. 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.

21. 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 surgery • Impairment group – 01.2 – Stroke with right body involvement • Etiologic diagnosis – 434.91 – Cerebral artery occlusion with infarction • Comorbidities - V45.81 – Aortocoronary bypass status - 787.2 - Dysphagia

22. Impairment Group #02 – Brain Dysfunction • Brain dysfunction – Non-traumatic • Injury to brain/neural tissue not resulting from trauma, as in: • Mass occupying lesions (eg: tumors, cysts) • If lesion excised due to craniotomy, code patient in non-traumatic brain dysfunction group • Infectious processes (eg: meningitis) • Metabolic disorders (eg: secondary to poisonings, global anoxia/hypoxia) • Structural disorders (eg: secondary to hydrocephalus)

23. 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

24. 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)

25. 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

26. Physician Documentation Highlights • These are examples of neurological disorders that count as a 75% admission • Spinal Muscle Atrophy • Dermatomyositis • Peroneal Muscular Atrophy • Polymyositis • Dematomyositis • Other Myopathies • Toxic Myopathy • Critical illness Myopathy • Myopathy in endocrine diseases • Symptomatic inflammatory myopathy in diseases classified elsewhere

27. 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, meningioma • Infectious cause – examples: abcess, HIV/AIDS • Autoimmune disease – example: transverse myelitis • Vascular disease – example: A-V malformation, “stroke” of spinal cord

28. 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.

29. 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

30. Impairment Group #04 – Spinal Cord Dysfunction • NOTE: • When spinal cord dysfunction patients are re-admitted 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.

31. 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.

32. Impairment Group #05 – Amputation of Limb • If more than one condition led to the impairment, etiologic diagnosis should be that “most proximal” to the impairment • 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

33. 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

34. Impairment Group #07 – Pain Syndromes • Use when primary reason for admission is treatment of pain • 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.

35. Impairment Group #08 – Orthopedic • Group includes coding for joint replacement and post-fracture 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.

36. 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

37. 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

38. 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

39. 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

40. 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

41. Impairment Group #13 – Other Disabling Impairments • This group employed as a “last resort” • Often patients placed in this group should be “debility” patients

42. 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)

43. Impairment Group #15 – Developmental Delay • Group is employed for impaired cognitive or motor function expressed as developmental delay

44. Impairment Group #16 – Debility • Group assigned where there is generalized weakness/deconditioning, often secondary to illness or surgery • 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

45. 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 assigned • Etiologic diagnosis is disease or injury leading to the debility

46. 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

47. Coding Best Practices

48. Coding – Best Practices • Pre-Admission Screening: Include all diagnoses, co-morbidities, and Rehab Impairment Code (RIC); • Physician clearly identifies the RIC, Etiologic Diagnosis, and co-morbidities in the History and Physical and Discharge Summary • 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

49. 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 / diagnoses. • 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.

50. ICD-9-CM Coding Guidelines: Variances Between the UB-92 and the IRF-PAI Forms