Coding Cerebral Palsy & Developmental Delay

chwcdi

Providers in our institution frequently document patient history to the effect of 'medically complex patient with CP, DD...' (wherein CP means cerebral palsy and DD means developmental delay). There is no specificity for what 'developmental delay' means which we are addressing on  a separate note (Physical? Intellectual? Both?).

Our question is: Does your institution code both the cerebral palsy and the developmental delay or is the delay considered integral to the CP and not coded?

jackietouch@aol.com

Yes, we capture both. Our physicians are very good about documenting if delay is global so we capture F88 instead of R6250. If not specified as global and we have strong indicators to clarify for global delay from the documentation, we will clarify if delay is global or not.

If documentation uses the outdated term "MRCP" (mental retardation cerebral palsy) or the newer "CPID" (cerebral palsy intellectual disability), we will clarify for degree of intellectual disability (may impact ROM in APR-DRG).

chwcdi

Jackie, when you seek to clarify degree of intellectual disability how do you differentiate the degree of delay within your query? Do your providers utilize IQ specifically or are there other criteria they use?

jackietouch@aol.com

When clarifying for degree of intellectual disability, we ask if the degree can by clinically determined and offer choices of mild, moderate, severe, profound, unable to clinically determine or other. We do not clarify for degree of delay (there are no codes that differentiate degree of delay).

We are usually only clarifying in cases that appear from the documentation to be severe or profound. It is very difficult to ascertain from documentation a mild or moderate degree and these usually do not impact the DRG. If there happens to be a specialist note or notation of IQ testing in the medical record, we may clarify for mild or moderate, but this is extremely rare.