I am continuing my project, “A Question a Day Keeps the Query Away,” and today’s topic is functional quadriplegia. Let me preface this TalkBack with: this is an example of a coding construct that does not have a clinical diagnosis correlate. These types of diagnoses drive some physicians crazy. When I was taught about this diagnosis during my orientation to become a physician advisor for the CDI team, I relished being given a way to convey how sick and complex my patients were, but other clinicians may be purists.
On September 27, 2007, there was a presentation and discussion at the ICD-9 Coordination and Maintenance Committee meeting requesting a code for functional urinary incontinence and for functional quadriplegia. Those codes were granted, became effective October 1, 2008, and were also incorporated into ICD-10-CM. It was felt these codes would help the assessment of long-term nursing care needs.
Functional quadriplegia, ICD-10-CM code R53.2, is defined as being complete immobility due to severe disability or frailty caused by another medical condition, without physical injury or damage to the brain or spinal cord. The patient with functional quadriplegia requires assistance with all activities of daily living. My CDI friend, Katy Good, expresses it as a patient who is functionally quadriplegic due to an underlying condition. The Fall 2007 Coordination and Maintenance Committee meeting Summary notes documented Dr. Laura Powers from the American Academy of Neurology describing it as being “the inability to move due to another condition like severe contractures, arthritis, etc., and functionally you are the same as a paralyzed person.”
This is in contradistinction to the paralyzed patient with a cervical spine fracture and spinal cord injury. The patient with a pontine hemorrhage who has locked-in syndrome and can only move their eyes. Those patients are structural, neurologic, or spinal quadriplegics. Their code set is found in Chapter 6, Diseases of the nervous system, G00-G99.
Examples of functional quadriplegia are the advanced dementia patient with contractures from disuse who has not been out of bed in years and the terminal Lou Gehrig’s disease patient. Patients may have multiple sclerosis or Huntington’s disease, profound intellectual disability, severe birth defects, or advanced musculoskeletal deformities such as severe crippling rheumatoid arthritis.
Verbiage or clues to the CDIS or coder that functional quadriplegia may be present include words like, “bedbound,” “bedfast,” or “bedridden,” which are coded as Z74.01, Bed confinement status, and notations from the physical, occupational therapist or bedside nurse that a patient requires total care, major assistance with all ADLs, or has a low Braden score specifically in terms of activity and mobility. The purpose of the Braden score is to prognosticate the risk of pressure ulcers.
My recommendation is to make sure that you offer some education to the provider prior to querying. The term, “functional quadriplegia,” may have no context for them if they have never been introduced to it.
If they need convincing that it really is a thing, present them with the article by Charilaou et. al., including our friend, Dr. Jim Kennedy, entitled, “Functional Quadriplegia: A Nationwide Matched Study of Trends in Hospital Resource Utilization and Associated Comorbidities,” found in the Annals of Long-Term Care from 2019. This article detailed how patients with functional quadriplegia had much longer lengths of stay and higher costs as compared to matched controls in similar DRGs who did not have functional quadriplegia.
The risk adjustment implications of functional quadriplegia are identical to those of structural or neurologic quadriplegia. Both are major comorbid conditions or complications (MCCs) and both land in Hierarchical Condition Categories (HCC) 70.
If the hospital is going to have to expend resources to care for a severely impacted patient who is in the hospital for an extended amount of time, they should be able to get credit for it. Get the provider to use the term, functional quadriplegia, when it is applicable.
Imagine receiving notice that your healthcare organization faces a potential multimillion-dollar repayment demand based on the review of just 100 claims. This scenario, playing out
Some of you may have read my article from last week kindly published as a special bulletin. For those who did not, let me recap.
Please log in to your account to comment on this article.
Physician queries are essential for accurate documentation and claims data, but they are increasingly scrutinized by payors, leading to denials and revenue leakage. This webcast, led by industry expert Cheryl Ericson, RN, MS, CCDS, CDIP, provides actionable strategies to craft compliant queries, reduce denials, and enhance revenue integrity. Attendees will gain insights into clinical validation queries, how to avoid common pitfalls, and learn best practices to defend against query denials. Don’t miss this opportunity to refine your query process and protect your organization’s financial health.
Master the complexities of heart failure coding with this expert-led webcast by Emily Montemayor, CCS, CMBCS, COC, CPC, CPMA. Discover strategies to ensure compliance with ICD-10-CM guidelines, documentation integrity, and capture comorbidities like CKD and hypertension. Learn how to resolve coding challenges, improve documentation practices, and submit clean claims to minimize denials and safeguard your organization’s financial health. With practical insights and real-world examples, this session equips you to prevent revenue leakage, enhance compliance, and secure optimal reimbursement—all while supporting better patient outcomes.
Prepare your organization for the 2025 OPPS updates with expert insights from Tiffani Bouchard, CCS, CRCR, a Revenue Integrity Professional with over 30 years of experience. This webcast will address critical challenges in charge capture and coding, providing clarity on APC policies, C-APC packaging, exclusions, and payer-specific requirements. Attendees will learn actionable strategies to ensure compliance, optimize reimbursement, and mitigate risks of claim denials. Gain the knowledge needed to implement updates effectively, educate your team, and maintain seamless revenue cycle operations in the face of evolving OPPS complexities.
Join Beth Wolf, MD, CPC, CCDS, for an in-depth webcast on the FY2025 spinal fusion MS-DRG updates. Discover key changes in DRG classification, understand impacts on documentation and CMI, and learn strategies to ensure compliance.
Dr. Ronald Hirsch dives into the basics of Medicare for clinicians to be successful as utilization review professionals. He’ll break down what Medicare does and doesn’t pay for, what services it provides and how hospitals get paid for providing those services – including both inpatient and outpatient. Learn how claims are prepared and how much patients must pay for their care. By attending our webcast, you will gain a new understanding of these issues and be better equipped to talk to patients, to their medical staff, and to their administrative team.
Hospitals face growing challenges in measuring observation metrics due to inconsistencies in classification, payer policies, and benchmarking practices. Join Tiffany Ferguson, LMSW, CMAC, ACM, and Anuja Mohla, DO, FACP, MBA, ACPA-C, CHCQM-PHYADV as they provide critical insights into refining observation metrics. This webcast will address key issues affecting observation data integrity and offer strategies for improving consistency in reporting. You will learn how to define meaningful metrics, clarify commonly misinterpreted terms, and apply best practices for benchmarking, and gain actionable strategies to enhance observation data reliability, mitigate financial risk, and drive better decision-making.
The 2025 Medicare Physician Fee Schedule brings significant changes to payment rates, coverage, and coding for physician services, impacting practices nationwide. Join Stanley Nachimson, MS., as he provides a comprehensive guide to understanding these updates, offering actionable insights on new Medicare-covered services, revised coding rules, and payment policies effective January 1. Learn how to adapt your practices to maintain compliance, maximize reimbursement, and plan for revenue in 2025. Whether you’re a physician, coder, or financial staff member, this session equips you with the tools to navigate Medicare’s evolving requirements confidently and efficiently.
Dr. Ronald Hirsch provides critical details on the new Medicare Appeal Process for Status Changes for patients whose status changes during their hospital stay. He also delves into other scenarios of hospital patients receiving custodial care or medically unnecessary services where patient notifications may be needed along with the processes necessary to ensure compliance with state and federal guidance.
Copyright © 2025 RACmonitor. Powered by MedLearn Media.
Prepare for the 2025 CMS IPPS Final Rule with ICD10monitor’s IPPSPalooza! Click HERE to learn more
Get 15% OFF on all educational webcasts at ICD10monitor with code JULYFOURTH24 until July 4, 2024—start learning today!
CYBER WEEK IS HERE! Don’t miss your chance to get 20% off now until Dec. 2 with code CYBER24
