Functional Quadriplegia

I am looking for some feedback on the diagnosis of functional quadriplegia. I have a patient with MS who has been admitted for debridement of a coccyx pressure ulcer which has been exaccerbated due to his limited mobility. He is unable to feed himself and has contractures in his upper and lower extremities. My interpretation of the coding clinic is that because he has an underlying neurological condition that has progressed and has caused the immobility, functional quadriplegia would not be appropriate.

Any thoughts would be appreciated.

Functional Quadriplegia
Coding Clinic 4th Qtr. 2008, p. 143

Functional quadriplegia is not a true paresis. It is the inability to move due to another condition (e.g., dementia, severe contractures, arthritis, etc.). The patient is immobile because of a severe physical disability or frailty. There is usually some underlying cause, which most often will involve severe dementia. The individual does not have the mental ability to ambulate and functionally is the same as a paralyzed person.

Instructional notes in the Tabular indicate that neurologic quadriplegia (344.00-344.09), hysterical paralysis (300.11) and immobility syndrome are excluded from code 780.72.

Comments

  • I interpret that to mean that if the physician has diagnosed quadriplegia due to a neurologic deficit affecting a particular cervical segment (particularly as in spinal cord injury), that you would not want to use the 780.72 code, as the 344.0x code is more specific. So in your situation, if the physician has not diagnosed quadriplegia but you believe the clinical situation describes a patient without practical use of any limbs, I think you can ask for a diagnosis of functional quadriplegia.

    Renee


    Linda Renee Brown, RN, CCRN, CCDS
    Certified Clinical Documentation Specialist
    Banner Good Samaritan Medical Center
  • edited April 2016
    I agree with Renee.

    Dawn
  • Looks nice and I will 'borrow'...only suggestion would be to add a box
    for "NONE" as a possible response given we should allow for the
    responder to disagree that the condition subject of the query is not
    present.

    Thanks for sharing,

    Paul Evans, RHIA, CCS, CCS-P
    Supervisor, Clinical Documentation Integrity, Quality Department
    California Pacific Medical Center
    2351 Clay #243
    San Francisco, CA 94115
    Cell: 415.637.9002
    Fax: 415.600.1325
    Ofc: 415.600.3739
  • Good Idea. Thanks!
  • edited April 2016
    HI,

    Thank you so much for sharing it!

    I agree with the other response to add a box for "NONE" or "No, I disagree."

    One more thought was to add the RN's braden scale - if done at your hospital. There are 2 areas of that assessment that might be useful to support query if the RN gave patient a 1 or a 2:
    ACTIVITY
    1. Bedfast Confined to bed.
    2. Chairfast - Ability to walk severely limited or
    non-existent. Cannot bear own
    weight and/or must be assisted into
    chair or wheelchair.

    MOBILITY
    1. Completely Immobile - Does not make even slight
    changes in body or extremity
    position without assistance
    2. Very Limited - Makes occasional slight changes in
    body or extremity position but
    unable to make frequent or
    significant changes independently.

    Have a great day,
    Kara
  • There are query forms on the ACDIS website with definitions that may be helpful .

    Paul Evans, RHIA, CCS, CCS-P, CCDS

    Manager, Regional Clinical Documentation & Coding Integrity
    Sutter West Bay
    633 Folsom St., 7th Floor, Office 7-044
    San Francisco, CA 94107
    Cell: 415.637.9002
    Fax: 415.600.1325
    Ofc: 415.600.3739
    evanspx@sutterhealth.org

    [cid:image001.jpg@01CF2321.2BF84EA0]


  • This diagnosis is so tricky, especially since it's not something the MD's are used to using. My understanding is that it applies to those patients who function as a quadriplegic without spinal cord damage/true paresis. Dementia would be the most common underlying cause but I have also seen it used in reference to patients with terminal MS, severe arthritis, or extreme frailty.
    I think the most important piece is that this is not severe deconditioning (critical illness myopathy would be a better route for this). FQ is something that will not improve. It is permanent. Clinical indicators are often found in the nursing notes with evidence that the patient is 'bedbound', severe contractures, decubiti, etc....

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404
  • edited April 2016
    I agree with Katy and could not have said it better myself.

    Mary A Hosler MSN, RN
    Clinical Documentation Specialist
    Alumnus CCRN
    McLaren Bay Region
    1900 Columbus Ave.
    Bay City, Michigan 48708
    (989) 891-8072
    mary.hosler@mclaren.org

    "The difference between the right word and the almost right word is the difference between lightning and the lightning bug." Samuel "Mark Twain" Clemens
  • edited April 2016
    Thank you all-that helps!

    Kerry
  • That is exactly how we use to document FQ, it cannot be with any neurological defect, like CVA, TBI etc. that is the cause of quadriplegia

    Debra Stewart RN, BSN
    Clinical Documentation Specialist
    Sentara/Halifax Regional Hospital
    South boston, va. 24592
    (434)-517-3317 Work
    (434)-222-9884 Cell
  • edited April 2016
    What about MS?

    Thanks again,

    Kerry
  • I think there is variation here. I have seen it suggested that if the quadriplegia is related to neurologic damage, it is not FQ. But I have also heard the opposite and that terminal MS or Anoxic brain damage could be associated with FQ.

    From Dr. Gold:
    1. "Mary, functional quadriplegia is less a clinical diagnosis and more a management diagnostic entity. Inability of a patient to move around because of weakness isn't it. Imagine a person who has had such severe neurologic deterioration from such things as terminal MS or muscular disuse atrophy in advanced Alzheimer's disease or anoxic brain damage and who hasn't moved for months and has contractures of all four extremities from nonuse that ALL activities of daily living have to be provided by someone else. The patient has to be fed, turned, cleaned of fecal material and urine (unless there are stomas). They breathe on their own and the internal organs work, but that's about it. There's a good description in AHA's Coding Clinic for reference. The issue is the increased amount of care that has to be delivered to such a compromised patient while in the hospital for something else.

    Yes, overuse of this code will be scrutinized, especially if it suddenly appears all over at a facility and is the only MCC. But the reason to be in the acute care hospital is because a treatable illness occurred that needs inpatient hospital treatment. Then the patient can go back to the SNF or LTACH.

    I would converse with the nursing staff to see what abilities the patient has and if that is requiring significant staffing issues and may be interfering with treatment. Pressure ulcers may be a reason for inpatient care BECAUSE of the patient's functional quadriplegia. The patient may have recurrent episodes of acute aspiration pneumonitis related to the total inability to protect one's self. Do a "drive-by" and check the patient. If the condition is clinically insignificant, I wouldn't go after it.

    Dr. G. "
    http://www.cditalk.com/threads/515-Functional-quadriplegia

    from ACP

    "The most common cause of functional quadriplegia is advanced neurologic degeneration from dementia, hypoxic injury, amyotrophic lateral sclerosis, Huntington's disease, multiple sclerosis or similar conditions. However, some birth defects or advanced musculoskeletal deformity (including severe, progressive arthritis) may result in functional quadriplegia"



    http://www.acphospitalist.org/archives/2012/05/coding.htm


    2.
    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404
  • edited April 2016
    This additional info was very helpful. Thank you for sharing-it is exactly what I was looking for.

    Kerry
  • This is such a sticky issue because there isn’t any great guidance on this diagnosis. I definitely think this dx should be reserved for the most severe cases but I don’t necessarily think that this mean that they cannot move at all. I worked inpatient in a resp ICU for a couple years where we had a lot of patients with quadriplegia either due to a traumatic injury or due degenerative conditions like ALS and MS. We had quadriplegics that had partial function of their upper extremities and could use a wheelchair and we had ones that we needed to reposition their pinkie. There is a continuum that has to be considered.
    Patients with end stage MS, dementia, etc may meet the definition of functional quadriplegia while still being able to make some movements. I think what we have to be most aware of is whether the record truly supports the diagnosis. So we have plenty of evidence in the record to show that these patients are debilitated to the point that they function at the level of a quadriplegic? Is this condition indefinite (it will not improve with PT/time)?

    If the patient condition is well described, I think you may be able to support this dx. That being said, I expect this dx to be a denial target at some point. We have not seen that YET. But when it does I will be curious how auditors are defining this dx and I may be signing a different tune at that point ;-).

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    AHIMA Approved ICD-10CM/PCS Trainer
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404
  • My personal opinion here:

    Functional quadriplegia does not refer to patients that simply can't accomplish self-care. It refers to patients who function as a quadriplegic however do not have a spinal cord injury. Even if the patient cannot care for themselves, if they can move their arms and legs, I would not consider them functionally quadriplegic.

    Just my thoughts....

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404

    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Wednesday, April 13, 2016 10:47 AM
    To: Kathryn Good
    Subject: [cdi_talk] functional quadriplegia

    Is anyone trying to capture " functional quadriplegia" for someone who is morbidly obese?
    I have a patient with a BMI of 91.0. nursing notes reflect bedbound, cannot do any of her care, 4 person assist bed to bed transfer.....

    Just a thought.
    Thanks in advance!

    Lona McNamara, RN, BSN, CCM




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  • Per 2016 CDI Pocket Guide "Functional Quad"



    Definition

    Functional quadriplegia is the lack of ability to use one's limbs or to ambulate due to extreme debility, not due to spinal cord injury. . .



    Typically the patient requires "total care". The usual findings are: bedridden, inability to turn, unable to feed or groom self, urinary/fecal incontinence, may have contractures.



    Braden scores:

    * Mobility = 1 (completely immobile) or 2 (very limited)

    * Activity = 1 (bedridden)



    ADLs: High degree of disability or dependence, incontinence, complete immobility. Not simply "need assistance".



    Common Causes:

    * Severe, end-stage dementia

    * Advanced progressive neuro-degenerative disorders (e.g. multiple sclerosis, ALS)

    * Severe intellectual disability (formerly mental retardation)

    * Severe brain injury/brain damage

    * Advanced, crippling arthritis






    Charlene Thiry, RN, BSN, CPC, CCDS
    Clinical Documentation Specialist
    Phone: 913-796-5944
    charlene.thiry@TrustHCS.com
    www.TrustHCS.com



  • Per the coding guidelines: Functional quadriplegia is the lack of ability to use one's limb's or to ambulate due to extreme debility.


    I agree with Katy.

    Sandra Steed, RN, CCDS, CCS
    CDI Educator
    New Hanover Regional Medical Center
    Sandra.steed@nhrmc.org
    Cell: 910-465-0147



  • Yes, I agree with this definition. If the patient is so obese they cannot move their arms and legs, I think the dx may be supported. If they need help with ADL's because they are unable to perform these tasks but can move their arms and legs, I think this is a different story.

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404


  • I wonder where they got this definition from? I have never seen another definition of Func quad state that the inability to ambulate due to extreme disability is indicative func quad. This seems like it may be one possible indicator but plenty of patients cannot walk due to underlying condition/frailty but I would be very hesitant to suggest they have func quadriplegia. Maybe myopathy in those cases...

    This is a tough dx because I have never really seen it in medical literature so there is very little guidance.

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404


  • I think if they can move arms feed or use remote...not FQ...


  • References cited in the Guide are:

    ICD-10-CM Official Guidelines Section I.C.18.f
    CMS Open Door Forum (2/14/13)" Clarification related to active diagnoses and quadriplegia. See http://www.health.state.mn.us/divs/fpc/profinfo/cms/activediagnosis.html


    Hope I got that typed correctly!




    Charlene Thiry, RN, BSN, CPC, CCDS
    Clinical Documentation Specialist
    Phone: 913-796-5944
    charlene.thiry@TrustHCS.com
    www.TrustHCS.com



  • Hmmm... I don't see anything about ambulation there:

    "CMS further indicated functional quadriplegia "refers to complete immobility due to severe physical disability or frailty." Conditions such as cerebral palsy, stroke, pressure ulcers, contractures, advanced dementia, etc. can also cause functional paralysis that may extend to all limbs hence, the diagnosis functional quadriplegia. For individuals with these types of severe physical disabilities, where there is minimal ability for purposeful movement"

    http://www.health.state.mn.us/divs/fpc/profinfo/cms/activediagnosis.html

    I would stick to complete immobility as a requirement for func quadriplegia. Of course this doesn't mean they can move a pinky. Just like in quadriplegia caused by spinal cord injury you still may have some movement but it would be severely impaired and probably not often purposeful.


    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404


  • Not sure my response came through earlier.

    2016 ICD-10 CM page 18 Coding Guidelines: Functional quadriplegia is the lack of ability to use one's limb's or to ambulate due to extreme debility.

    It the pt is feeding herself, moving extremities, etc would not clinically meet.

    Sandra Steed, RN, CCDS, CCS
    CDI Educator
    New Hanover Regional Medical Center
    Sandra.steed@nhrmc.org
    Cell: 910-465-0147







  • It's that 'or' that's tricky, right? Someone may read that to mean that either an either/or whereas I would think its and 'and'. These nuances matter because interpretation can be variable.

    Katy Good, RN, BSN, CCDS, CCS
    Clinical Documentation Program Coordinator
    Flagstaff Medical Center
    Kathryn.Good@nahealth.com
    Cell: 928.814.9404


  • edited May 2016
    Agree with Katy.
    If after the person is bathed, propped, turned, positioned, he or she can then sit in the bed and hold a book, reach for a call bell or eat independently-in my opinion, that person does not qualify as they have use of upper extremities.

    Kerry Seekircher, RN, BS, CCDS, CDIP




  • Sort of on topic...
    I almost queried to clinically validate (thinking it was wrong) quadriplegia. Then the wrote incomplete quadriplegia... Then I found this. It surprised me ...

    It's still an MCC.

    I'm not talking about functional. Just thought an interesting relevant finding:
    http://www.spinal-injury.net/incomplete-quadriplegia.htm



  • edited May 2016
    So, does "the inability to move due to severe disability or frailty caused by another medical condition without physical injury or damage to the brain or spinal cord" exclude a patient with a persistent vegetative state from also being functional quadriplegic?

    In this definition below, it notes "damage to brain" in addition to SCI.

    -Jane

    From: CDI Talk [mailto:cdi_talk@hcprotalk.com]
    Sent: Wednesday, April 13, 2016 10:57 AM
    To: Hoyt, Jane
    Subject: RE:[cdi_talk] functional quadriplegia

    Thanks Katy,

    I don't disagree.

    However, I recently came upon a definition of Functional quadriplegia that states: "functional quadriplegia is not a true paresis. It is the inability to move due to severe disability or frailty caused by another medical condition without physical injury or damage to the brain or spinal cord. Requires total care- fully dependent for ADLs; seen most often in dementia, Parkinson's, CVA, MS, CP.

    So, today this particular case had me wondering.



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