Documentation for the IRF Provider Timothy N. Brundage, MD, CCDS Certified Clinical Documentation Specialist DrBrundage@gmail.com 1 Medicare controls the ball field If you want to play ball, you have to play by their rules Many Payors follow the Center for Medicaid and Medicare Services (CMS) guidelines 2 1
Diagnosis based coding language Problem-specific H&P s, consultations, daily progress notes, etc. Do not document?diagnosis PMHx needs to be in the correct location of the H&P If its in the assessment and plan please use active language Acute Acute on Chronic Sequelae of Stroke (not h/o) Hypertension should be documented if antihypertensive medications are reviewed as a part of the H&P Possible, Probable, Likely, Suspected... NOT acceptable language for coding at IRF level Tiering Tier Tier 2 Tier 1 Sick Sicker Sickest Morbid obesity C. diff Paralysis of vocal cords Anoxic brain damage Pseudomonas infection Tracheostomy Left heart failure Dysphagia ESRD on HD 4 2
IRF Specific Documentation 5 ICD-10 code Description Tier J8.01 Paralysis of vocal cords and larynx, unilateral 1 J8.02 Paralysis of vocal cords and larynx, bilateral 1 J8.4 Edema of the larynx 1 (Edema of glottis, subglottic edema, supraglottic edema) Z9.0 Tracheostomy status 1 Z99.2 Dependence on renal dialysis 1 Z4.0 Encounter or attention to tracheostomy 1 J8.00 Paralysis of vocal cords and larynx, unspecified 6
ICD-10 code Description Tier B96.5 Pseudomonas aeruginosa as the cause of diseases classified 2 elsewhere A04.7 Enterocolitis due to Clostridium difficile 2 I69.91 Dysphagia following CVA 2 R1.10 Dysphagia, unspecified 2 R1.11 Dysphagia, oral phase 2 R1.12 Dysphagia, oropharyngeal phase 2 R1.1 Dysphagia, pharyngeal phase 2 R1.14 Dysphagia, pharyngoesophageal phase 2 R1.19 Dysphagia, other 2 K91.2 Postsurgical malabsorption, not classified elsewhere 2 7 ICD-10 code Description Tier E66.01 Morbid obesity due to excess calories N17.9 Acute Kidney Failure, unspecified N17.0 ATN E10.9 DM type 1 without complication E11.21 Type 2 with diabetic nephropathy / diabetic CKD E11.69 Type 2 DM with other specified complication J18.9 Pneumonia, unspecified organism G81.90 Hemiplegia, unspecified affecting unspecified side G81.92 Hemiplegia, unspecified affecting L dominant side I50.2 Chronic diastolic heart failure (HFpEF) I50.22 Chronic systolic heart failure (HFrEF) G9.1 Anoxic brain damage (includes anoxic encephalopathy) E11.9 Type 2 DM without complications -- 4
Central nervous system infarction is defined as brain, spinal cord or retinal cell death attributable to ischemia Neuropathological Neuroimaging Clinical evidence of permanent injury Dysphagia following stroke is a Tier 2 Hemiplegia is a Tier Document if dominant side for ICD-10 AHA/ASA Expert Consensus Document An Updated Definition of Stroke for the 21 st Century www.stroke.ahajournals.org/content/44/7/2064 Published May 201 9 Site: Artery Vertebral Basilar anterior and posterior Communicating middle cerebral Anterior and posterior cerebral carotid Laterality Etiology Hemorrhage Occlusion Stenosis Thrombosis Embolism Linkage to underlying condition Atrial fibrillation Hypertension Linkage to alcohol, drug or tobacco Use Abuse Dependence 10 5
ICD-10 code Description PDx/Tier I6.9 Cerebral infarction, unspecified (stroke NOS) I6.11 Cerebral infarction due to thrombosis of R MCA I6.12 Cerebral infarction due to thrombosis of L MCA I6.19 Cerebral infarction due to thrombosis of unspecified MCA I6.411 Cerebral infarction due to embolism of R MCA I6.412 Cerebral infarction due to embolism of L MCA I6.419 Cerebral infarction due to embolism of unspecified MCA I6.511 Cerebral infarction due to unspecified occlusion or stenosis of R MCA I6.512 Cerebral infarction due to unspecified occlusion or stenosis of L MCA I6.519 Cerebral infarction due to unspecified occlusion or stenosis unspecified MCA Diagnoses Hemiplegia Hemiparesis Monoplegia of lower limb Monoplegia of upper limb Monoplegia, unspecified Ambidextrous patients default is dominant Right side dominant is the default Left side non-dominant is the default 12 6
ICD-10 code Description Tier I69.91 Dysphagia following cerebral infarction 2 I69.891 Dysphagia following other cerebrovascular disease 2 G81.91 Hemiplegia, unspecified affecting R dominant side G81.92 Hemiplegia, unspecified affecting L dominant side 1 Laterality Right Left Unspecified Type Concussion Traumatic cerebral edema Diffuse traumatic brain injury Focal traumatic brain injury Unspecified Contusion & Laceration Traumatic hemorrhage Contusion, laceration & hemorrhage Epidural hemorrhage Traumatic subdural hemorrhage Traumatic subarachnoid hemorrhage Other specified Injury of Specify complication with With LOC (document time in minutes/hours) With or without return to previous LOC With or without death W/o LOC Site Cerebrum Cerebellum Brainstem Internal carotid A Intracranial portion unspecified Timing Initial Subsequent Sequela 14 7
Site Carotid siphon & bifurcation MCA Ant communicating A. Post Communicating A. Vertebral A. Other intercranial As. Unspecified Ruptured berry aneurysm Ruptured cerebral aneurysm Other Unspecified Laterality Right Left Unspecified 15 ICD-10 code Description G5 Multiple Sclerosis G61.0 Guillain-Barré syndrome G61.81 Chronic inflammatory demyelinating polyneuritis G12.21 Amyotrophic lateral sclerosis 16 8
KDIGO: increase in the patient s serum creatinine of 0. mg/dl or more over their normal baseline level Link Dehydration Azotemia Do Not document Acute Renal Insufficiency Acute Renal Failure is a Tier 17 ICD-10 code Description Tier N17.9 Acute Kidney Injury Tier N17.0 ATN Tier N28.9 Acute Renal Insufficiency Disorder of Kidney, unspecified E86.0 Dehydration -- E86.1 Hypovolemia -- E86.9 Volume Depletion -- -- N19 Unspecified Kidney Failure (Uremia NOS) -- 18 9
Acute or Chronic Acute on Chronic Exacerbation Decompensated Systolic (EF < 40%) HFrEF Diastolic (normal EF) HFpEF Both Simply writing EF= % is not sufficient 19 ICD-10 code Description Tier I50.20 Systolic HF I50.21 Acute Systolic HF I50.22 Chronic Systolic HF I50.2 Acute on Chronic Systolic HF I50.0 Diastolic HF I50.1 Acute Diastolic HF I50.2 Chronic Diastolic HF I50.40 Combined Systolic & Diastolic HF I50.41 Acute Combined Systolic & Diastolic HF I50.9 CHF -- 20 10
Type 1 or Type 2 or due to underlying condition Drug induced (steroids) or gestational Postpancreatectomy (Whipple) With hypo or hyperglycemia With coma Without coma With DKA Diabetes related complications: Diabetic peripheral neuropathy Diabetic nephropathy Diabetic vasculopathy, etc. 21 ICD-10 code Description Tier E10.21 / E10.22 DM type 1 with diabetic nephropathy / diabetic CKD E10.40 DM type 1 with diabetic neuropathy E10.52 DM type 1 with diabetic gangrene E10.649 DM type 1 with hypoglycemia w/o coma E10.65 DM type 1 with hyperglycemia E10.9 DM type 1 without complications 22 11
ICD-10 code Description Tier E11.21/ E11.22 DM type 2 with diabetic nephropathy / diabetic CKD E11.40 DM type 2 with diabetic neuropathy E11.52 DM type 2 with diabetic gangrene E11.621 DM type 2 with foot ulcer E11.649 DM type 2 with hypoglycemia w/o coma E11.69 DM type 2 with other specified complication E11.9 DM type 2 without complications -- 2 Morbid Obesity BMI > 40 Physician must ascribe clinical relevance to the BMI Cannot be taken from a calculated BMI BMI > 40 Morbid obesity BMI < 19 Underweight malnourished 24 12
ICD-10 code Description Tier E66.9 Obesity, unspecified -- E66.01 Morbid Obesity due to excess calories E66.1 Morbid Obesity with alveolar hypoventilation -- 25 Myopathy Disuse Steroid Alcoholic Uremic Acute muscle weakness from onset of acute illness Chronic inactivity leading to muscle disuse Extremity weakness that results from muscular atrophy A clinical diagnosis Suggested Impairment Group IGC 0.8 Neuromuscular disorders 26 1
ICD-10 code Description Tier G72.9 Myopathy, unspecified -- (includes disuse myopathy) G72.0 Drug-induced myopathy -- G72.1 Alcoholic myopathy -- G72.81 Critical illness myopathy -- G62.81 Critical illness polyneuropathy -- 27 K91.2 Post GI surgery with malabsorption Noted frequently, but not diagnosed TPN may be a link to this diagnosis ICD-10 code Description Tier K91.2 Postsurgical malabsorption, 2 not classified elsewhere 28 14
Predicted Mortality Rates for some disease processes: Community Acquired Pneumonia = 0.5% Sepsis = 10% Septic shock = 40% If the patient survives, your ratings will be much higher in the public quality reporting data because you took care of a sicker patient Goal: actual mortality lower than expected mortality 29 0 15