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.
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
Renee
Linda Renee Brown, RN, CCRN, CCDS
Certified Clinical Documentation Specialist
Banner Good Samaritan Medical Center
Dawn
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
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
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
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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
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
Kerry
Debra Stewart RN, BSN
Clinical Documentation Specialist
Sentara/Halifax Regional Hospital
South boston, va. 24592
(434)-517-3317 Work
(434)-222-9884 Cell
Thanks again,
Kerry
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
Kerry
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
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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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
I agree with Katy.
Sandra Steed, RN, CCDS, CCS
CDI Educator
New Hanover Regional Medical Center
Sandra.steed@nhrmc.org
Cell: 910-465-0147
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
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
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
"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
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
Katy Good, RN, BSN, CCDS, CCS
Clinical Documentation Program Coordinator
Flagstaff Medical Center
Kathryn.Good@nahealth.com
Cell: 928.814.9404
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
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
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.