Download ICD-10-CM Coding for Inpatient Rehabilitation Facilities (IRFs)

ICD-10-CM Coding for
Inpatient Rehabilitation
Facilities (IRFs)
Elsevier Clinical Solutions
Presented by:
Sarah A. Serling, CCS, CCS-P, CPC, COC, CEMC, CPC-I,
Approved ICD-10-CM/PCS Trainer
October 20, 2016
Objectives
In this webinar we will:
• Explain diagnosis coding for acute
inpatient rehabilitation services.
• Identify correct coding and
sequencing of ICD-10-CM diagnosis
codes on the claim form and the
Inpatient Rehabilitation Facility
Patient Assessment Instrument
(IRF-PAI).
• Apply the general and chapter
specific coding guidelines to assign
ICD-10-CM codes for common
inpatient rehabilitation diagnoses.
| 3
Introduction
The International Classification of Diseases,
10th Revision, Clinical Modification (ICD-10-CM)
codes are used to report inpatient rehabilitation
diagnoses.
Inpatient Rehabilitation Facilities (IRFs)
report ICD-10-CM codes on the:
 Insurance claim form (UB-04)
 Inpatient Rehabilitation Facility-Patient
Assessment Instrument (IRF-PAI).
IRFs report diagnoses on the claim form
according to the ICD-10-CM coding guidelines
and sequencing instructions. However, a
different set of rules and instructions apply to
reporting the diagnoses on the IRF-PAI.
| 4
What is Inpatient Rehabilitation?
Medical rehabilitation improves or restores function,
mobility, and independence to patients with disabilities
resulting from injury or a medical condition.
Inpatient medical rehabilitation is:
•
Also known as hospital-level or acute
rehabilitation care.
•
Unique, multifaceted care including medical,
physical, occupational, cognitive, behavioral,
and social issues.
•
For patients who need an intensive,
multidisciplinary rehabilitation program.
•
Appropriate for patients with complex nursing,
medical management, and rehabilitative needs.
| 5
Inpatient Medical Rehabilitation
Inpatient rehabilitation is an integral part of the continuum of care:
Acute hospital
care
Outpatient
care
Post-acute
care
 Post-acute care (PAC) includes medical and rehabilitative healthcare services for
patients after acute hospitalization, for continued treatment to recuperate or to
restore functional capabilities (or both).
| 6
Post Acute Care and Rehabilitation Providers
Post-acute care refers to a wide range of health care services delivered to patients
recently discharged from an acute hospitalization.
Long-term Care
Hospitals (LTCHs)
Inpatient
Rehabilitation
Facilities (IRFs)
PAC
rehabilitation
providers
Skilled Nursing
Facilities (SNFs)
Home Health
Agencies (HHAs)
 Different treatment protocols, regulations, classification criteria, and payment
structure in IRFs than other PAC rehabilitation settings.
| 7
Inpatient Rehabilitation Settings
The focus and intensity of care differentiates inpatient rehabilitation settings.
SKILLED NURSING FACILITIES (SNFS)
• Subacute skilled nursing services and rehabilitation care
• To transition patients from the acute care setting
• Less intensive rehabilitation and longer length of stay
LONG-TERM CARE HOSPITALS (LTCHS)
• Extended acute inpatient medical and rehabilitative care
• Treat medically complex patients requiring inpatient hospital level care for
more than 25 days
INPATIENT REHABILITATION FACILITIES (IRFS)
• Intensive rehabilitation therapy in a resource intensive hospital environment
• Includes close medical management and physician supervision, complex
nursing services, and intense multi-disciplinary therapy services.
ICD-10-CM Coding for Inpatient Rehabilitation Facilities
What are Inpatient Rehabilitation Facilities?
| 9
Defining Inpatient Rehabilitation Facilities
The Center for Medicare and Medicaid Services (CMS) has specific definitions
and classification criteria to distinguish IRFs from acute care hospitals and
other postacute care settings.
Definition: Inpatient Rehabilitation Facility (IRF)
 An inpatient rehabilitation hospital or a rehabilitation unit of an acute
care hospital.
 Provides intensive, interdisciplinary rehabilitation therapy and
management of comorbidities in a resource intensive inpatient
hospital environment with a high level of physician supervision.
 For patients with complex nursing, medical management, and
rehabilitation needs
| 10
Inpatient Rehabilitation Facility Patient Criteria
Patients must also meet defined criteria to be admitted to an IRF…
A rehabilitation physician must certify the patient:
 Medical condition and functional status require close
medical management and physician supervision,
complex nursing services, and intense
interdisciplinary therapy.
 Requires this type of specialized, intensive care due
to their complex nursing, medical management, and
rehabilitation needs, and
 Can be expected to benefit from and tolerate an
intensive rehabilitation program with multiple therapy
disciplines.
| 11
IRF Classification Criteria
IRFs have their own Medicare prospective payment system (PPS). Hospitals that meet
specific criteria receive higher IRF-PPS reimbursement. A key criterion to qualify for IRF
designation and IRF-PPS payment is the compliance threshold.
Compliance Threshold:
Percentage of the total inpatient population that requires
treatment in an IRF for one (or more) of certain medical
conditions specified by the CMS.
“60 Percent Rule”:
At least 60% of admissions have ≥ 1 of 13 specified
clinical conditions as a primary diagnosis or comorbidity.
 If the compliance threshold is not met, payment is based on the inpatient hospital
prospective payment system (IPPS) rather than the IRF-PPS.
| 12
IRF Compliance Threshold: Qualifying Conditions
1. Stroke
2. Spinal cord injury
3. Congenital deformity
4. Amputation
5. Major multiple trauma
6. Hip fracture
7. Brain injury
8. Neurological disorders (e.g., multiple sclerosis, Parkinson’s disease)
9. Burns
10. Arthritis (polyarticular rheumatoid, psoriatic, seronegative arthropathies)
11. Systemic vasculidities with joint inflammation
12. Severe or advanced osteoarthritis involving ≥ 2 major weight bearing joints
13. Hip or knee replacement (if bilateral, BMI is ≥ 50, or age is ≥ 85)
ICD-10-CM Coding for Inpatient Rehabilitation Facilities
IRF Coding and Reimbursement
| 14
IRF Prospective Payment System
The Inpatient Rehabilitation Facility Prospective Payment System (IRF-PPS):
• Higher base rate than the acute Inpatient Prospective Payment System (IPPS) rate.
• Case-mix adjusted payment for each admission to reflect expected resource needs
costs associated with a patient’s functional impairments and medical conditions.
• Payment is based on clinical characteristics and other patient information collected on
the Inpatient Rehabilitation Facility–Patient Assessment Instrument (IRF-PAI).
| 15
IRF Patient Assessment Instrument (IRF-PAI)
CMS requires a completed patient assessment instrument for all IRF patients, for each
IRF stay, at admission and discharge. The IRF-PAI:
• Items address physical, cognitive, functional, and psychosocial status.
• Data collected is used for payment and quality of care purposes.
• Requires ICD-10-CM codes for the etiologic diagnosis and comorbid conditions.
• IRF-PAI form must be included
in the IRF medical record
• IRF-PAI information must
correspond with the information
in the patient’s IRF medical
record.
| 16
IRF-PPS and the IRF-PAI
IRF-PAI data is used to classify IRF patients into case mix groups (CMGs) based
on clinical characteristics and the different resources required to provide care.
Rehabilitation
Impairment
Categories (RIC)
• Based on the primary reason for intensive rehabilitation care.
• Assigned by the grouper software
Case-mix groups
(CMG)
• Groups similar cases based on age, motor scores
and cognitive scores.
• Reported on claims with Health Insurance
Prospective Payment System (HIPPS) codes
Comorbidity Tiers
• Each comorbidity adds a higher
payment to the case.
• Four tiers: Tier 1, Tier 2, Tier 3, and
None
| 17
Codes Reported on the IRF-PAI
Impairment group
code (IGC)
• The primary condition requiring IRF care; NOT a diagnosis
code (a unique code developed for the IRF-PPS)
• Acute condition responsible for the impairment reported with
the IGC.
Etiology
Comorbidities
• ICD-10-CM codes for other conditions POA that are not
reported by the IGC or the etiology code.
Complications
• ICD-10-CM codes for conditions that develop after admission
to the facility.
 Codes for procedures are not reported on the IRF-PAI.
ICD-10-CM Coding for Inpatient Rehabilitation Facilities
IRF-PAI Coding
| 19
IRF-PAI Coding: Impairment Group Code
IRF-PAI coding first identifies the condition that requires rehabilitation. The Impairment
Group Code (IGC) represents the primary condition for which the patient requires
treatment in an IRF.
• The IGC is reported in item 21 of
the IRF-PAI.
• Each IGC maps to a Rehabilitation
Impairment Category (RIC).
• The admission IGC is used (by the
grouper software) to classify each
case into the RIC.
| 20
IRF-PAI Coding: IGC Examples
| 21
IRF-PAI Coding: ICD-10-CM Codes
ICD-10-CM codes for conditions are recorded in IRF-PAI item:
#22 - Etiologic Diagnosis
• The problem that led to the condition represented by the IGC.
• Reported in Item 22 using an ICD-10-CM code.
| 22
IRF-PAI Coding: ICD-10-CM Codes
ICD-10-CM codes are recorded in IRF-PAI item:
#24 - Comorbid Conditions - report secondary conditions which have significant
impact on the patients’ course of treatment for their primary diagnosis, that are not
already included in the IGC.
ICD-10-CM Coding for Inpatient Rehabilitation Facilities
Inpatient Rehab Coding Guidelines
| 24
Inpatient Rehabilitation Facility Coding Guidelines
Diagnosis coding rules differ for the inpatient rehabilitation facility claim form
(the UB-04) and the IRF-PAI.
1. IRF-PAI coding
• Completing assessment items on the on the IRF-PAI.
• Must adhere to the guidelines and definitions in the IRF PAI Training
Manual
1. ICD-10-CM coding
• Assigning diagnosis codes for billing purposes.
• Must adhere to the ICD-10-CM coding guidelines relevant to coding
inpatient and rehabilitation cases
| 25
Guidelines for IRF-PAI Coding
The IRF-PAI Training Manual contains IRF-PAI coding instructions…
https://www.cms.gov/medicare/medicare-fee-for-service-payment/inpatientrehabfacpps/irfpai.html
| 26
Guidelines for IRF Diagnosis Coding
ICD-10-CM Official Guidelines for Coding and Reporting are used to assign
principal and secondary diagnosis codes reported on the UB-04.
http://www.cdc.gov/nchs/icd/icd10cm.htm
| 27
Diagnosis Coding in the IRF Setting
Both codes and coding rules differ between the UB-04 and IRF-PAI (e.g.,
principal diagnosis versus etiologic diagnosis).
For example:
A patient is discharged after acute care hospital treatment for an acute
cerebral infarction with right dominant-sided hemiplegia and is admitted to the
IRF for rehabilitation for the late effects of the cerebral infarction (e.g.,
hemiplegia).
1. Principal diagnosis: Hemiplegia following a cerebrovascular infarction
(the condition requiring IRF care.)
2. Etiologic diagnosis: Cerebrovascular infarction (the acute condition
responsible for the condition requiring IRF care.)
| 28
Inpatient Rehabilitation Facility Coding Example
CODING EXAMPLE IRF-PAI VS. UB-04:
IRF-PAI:
UB-04
• Etiologic diagnosis: Acute cerebral
infarction with deficits
• Principal diagnosis: Sequelae of
cerebrovascular disease
• IGC: 01.2 Right Body
• I69.351, Hemiplegia and
hemiparesis following cerebral
infarction affecting right
dominant side
• RIC: Stroke (01)
• NOTE: Sequelae of cerebrovascular
disease is used only when an inpatient
program has been completed for the
same stroke prior to the current
admission, per IRF-PAI instructions.
ICD-10-CM Coding for Inpatient Rehabilitation Facilities
ICD-10-CM Coding for IRF Diagnoses
| 30
Inpatient Rehabilitation Facility Coding Example
INPATIENT REHAB FACILITY CODING SCENARIO:
A patient with difficulty walking is admitted to inpatient
rehabilitation after discharge from the acute care facility
status post bilateral total knee arthroplasty for treatment of
osteoarthritis in both knees. The patient is admitted to the
IRF for rehabilitative services, including physical therapy
and surgical aftercare.
How is this case coded?
| 31
Inpatient Rehabilitation Facility Coding Example
CODING EXAMPLE ANSWER:
Z47.1
Aftercare following joint replacement surgery
R26.2
Difficulty in walking, not elsewhere classified
Z96.653
Presence of artificial knee joint, bilateral
This is a rehabilitation admission for surgical aftercare. The
osteoarthritis no longer exists and is not coded. The patient has
difficulty walking (R26.2) and had both knees replaced (Z96.653).
| 32
Inpatient Rehabilitation Facility Coding Example
CODING EXAMPLE IRF-PAI VS. UB-04:
IRF-PAI:
• Etiologic diagnosis: Bilateral primary
osteoarthritis of knee
• IGC: Orthopedic Disorders (08) - 08.62
Bilateral Knee Replacements
• RIC: ReplLE (08)
• NOTE: If replacement is secondary to
arthritis, use the appropriate Orthopedic
Impairment Group code in item 21 but
with an arthritis ICD-10 code(s) for
Etiologic Diagnosis in Item 22
UB-04
• Principal diagnosis: Surgical Aftercare
• Z47.1 , Aftercare following joint
replacement surgery
• R26.2, Difficulty in walking, not
elsewhere classified
• Z96.653, Presence of artificial knee joint,
bilateral
| 33
IRF-PAI Coding Example
| 34
Inpatient Rehabilitation Facility Coding Example
INPATIENT REHAB FACILITY CODING SCENARIO:
Following acute hospitalization for chronic hypoxic respiratory failure, a
patient is transferred to the IRF unit for continued ventilator weaning
and occupational and physical therapy due to deconditioning and
debility.
The certifying physician documents the patient’s complex medical
problems as chronic hypoxic respiratory failure, ventilator dependent
requiring supplemental oxygen, COPD, and tracheostomy status.
| 35
Inpatient Rehabilitation Facility Coding Example
CODING EXAMPLE ANSWER:
Assign as the principal diagnosis.
• J96.11, Chronic respiratory failure with hypoxia
• The underlying reason for the debility and deconditioning is
coded as the principal diagnosis.
Assign as secondary diagnoses:
• J44.9, Chronic obstructive pulmonary disease, unspecified
• Z99.11 Dependence on respirator [ventilator] status, and
• Z93.0, Tracheostomy status.
| 36
Inpatient Rehabilitation Facility Coding Example
CODING EXAMPLE IRF-PAI VS. UB-04:
IRF-PAI:
• Etiologic diagnosis: Chronic
respiratory failure with hypoxia
• IGC: 17.51 Respiratory Disorders –
Ventilator Dependent
• RIC: Medically Complex Conditions
(17)
• NOTE: Includes respiratory cases
dependent on a ventilator upon
admission, regardless of whether a
weaning program is planned.
UB-04
• Principal diagnosis: Chronic
respiratory failure with hypoxia
(J96.11)
• J44.9, Chronic obstructive pulmonary
disease, unspecified;
• Z99.81, Dependence on supplemental
oxygen
• Z93.0, Tracheostomy status
| 37
IRF-PAI Coding Example
| 38
Inpatient Rehabilitation Facility Coding Example
INPATIENT REHAB FACILITY CODING SCENARIO:
A patient is admitted to an inpatient rehabilitation facility
following hospital treatment for an acute cerebral infarction
with residual aphasia and right hemiplegia (dominant side).
The patient’s Plan of Care includes occupational therapy,
physical therapy, and speech therapy.
How is this case coded?
| 39
Inpatient Rehabilitation Facility Coding Example
CODING EXAMPLE ANSWER:
Code as the principal diagnosis, the condition for which the
rehabilitation service is being performed (i.e., sequela of the
cerebral infarction.)
Assign codes:
• I69.320, Aphasia following cerebral infarction
• I69.351, Hemiplegia and hemiparesis following cerebral
infarction affecting right dominant side
• Sequence either code as the principal diagnosis.
| 40
Inpatient Rehabilitation Facility Coding Example
CODING EXAMPLE IRF-PAI VS. UB-04:
IRF-PAI:
UB-04
• Etiologic diagnosis: Acute cerebral
infarction with deficits
• Principal diagnosis: Sequelae of
cerebrovascular disease
• IGC: 01.2 Right Body
• I69.320, Aphasia following
cerebral infarction
• I69.351, Hemiplegia and
hemiparesis following cerebral
infarction affecting right
dominant side
• RIC: Stroke (01)
• NOTE: Sequelae of cerebrovascular
disease is used only when an inpatient
program has been completed for the
same stroke prior to the current
admission, per IRF-PAI instructions.
| 41
IRF-PAI Coding Example
| 42
Inpatient Rehabilitation Facility Coding Example
INPATIENT REHAB FACILITY CODING SCENARIO:
A patient is discharged from an acute hospital stay for a total hip
replacement due to a right intertrochanteric femur fracture and is
subsequently admitted to an inpatient rehabilitation facility for physical
therapy.
How is this case coded?
| 43
Inpatient Rehabilitation Facility Coding Example
CODING EXAMPLE ANSWER:
Assign as principal diagnosis, code:
S72.141D, Displaced intertrochanteric fracture of right femur,
subsequent encounter for closed fracture with routine healing
Assign as a secondary diagnosis:
Z96.641, Presence of right artificial hip joint
In this case, a total hip replacement was done to treat the traumatic
fracture of the hip. The fracture is now in the healing and recovery
phase after surgical treatment.
| 44
IRF Coding Guidelines: 7th Characters
In ICD-10-CM, certain codes require the 7th character ‘‘D’’ indicates that the patient is
receiving aftercare for the injury.
• If used on the IRF-PAI, ICD-10-CM diagnosis codes with the 7th character extension
“D” will not identify a case as meeting the IRF 60% rule requirements.
• In the IRF setting, a patient is defined as having a current diagnosis requiring the use
of the 7th character extension of ‘’A’’ if the patient requires current treatment for the
injury and if the diagnosis has a direct effect on the patient’s rehabilitation therapy
program in the IRF.
• ICD-10-CM codes with the 7th character extension of “D” are not included in the “List
of Comorbidities,” “ICD-10-CM Codes That Meet Presumptive Compliance Criteria,”
or “Impairment Group Codes That Meet Presumptive Compliance Criteria.”
| 45
In Conclusion…
ICD-10-CM coding of diagnoses in the post-acute
rehabilitation setting adheres to the same ICD-10-CM
coding guidelines and conventions as acute hospitals.
•
Determine the ICD -10-CM code that best describes
the primary reason for the patient’s admission to the
rehabilitation program.
•
Select the reason for admission to rehabilitation (the
impairment group code), then select the cause of the
IGC (the etiologic diagnosis).
•
Code comorbid conditions that are active (have a
direct impact on the patient’s current status, medical
treatments, nurse monitoring, or risk of death) and
are being monitored or treated.
| 46
References
1. IRF-PAI version 1.4 effective October 1, 2016

https://www.cms.gov/Medicare/Medicare-Fee-for-ServicePayment/InpatientRehabFacPPS/Downloads/IRF-PAI-Version-1-4.pdf
2. IRF-PAI version 1.4 Training Manual

https://www.cms.gov/medicare/medicare-fee-for-servicepayment/inpatientrehabfacpps/irfpai.html
3. International Classification of Diseases, Tenth Revision, Clinical
Modification (ICD-10-CM)

http://www.cdc.gov/nchs/icd/icd10cm.htm
| 47
You are invited to stay for a short overview on
Elsevier’s education solutions
ElsevierRevenueCycle.com
| 48
Elsevier Revenue Cycle Solutions
| 49
Elsevier’s Home Health Solution
A comprehensive online, continuing education course that helps home health
care professionals:
 Provide care to patients in their homes,
 Appropriately document and
 Accurately assign diagnosis codes
Mosby’s
Orientation to
Home Health
Care
Educode Home
Health Coding
Elsevier Home
Health Suite
Take a Look at our Educode Home Health Coding …
Interested in learning
more?
Visit ElsevierRevenueCycle.com
or call 866-416-6697