CASE #1 Stroke (#1) - hcmarketplace.comhcmarketplace.com/supplemental/1213_CASE_STUDIES_ONLY.pdf · EXHIBIT A 38 Inpatient Rehabilitation Facility Coding and Billing: A team approach

EXHIBIT A

36 Inpatient Rehabilitation Facility Coding and Billing: A team approach to correct code assignment

69

CASE #1Stroke (#1)

A right-handed 85-year old male has aspontaneous subarachnoid hemorrhage on the leftside of his brain resulting in right (dominant)sided hemiplegia, dysphasia and homonymoushemianopsia. This patient had a cerebralinfarction a year ago from which he has dysphagia(difficulty swallowing) as a late effect. He has hada gastrostomy tube since that time and receivestube feedings.

70

CASE #1Stroke (#1)

IRF-PAI

Impairment Group

01.2 Stroke with right body involvement

Etiology

430 Subarachnoid hemorrhage

Comorbid Conditions

784.5 Dysphasia

368.46 Homonymous hemianopsia

438.82 Dysphagia as late effect of prior oldstroke (Tier 2—excluded from RIC 01)

V44.1 Gastrostomy status

37Inpatient Rehabilitation Facility Coding and Billing: A team approach to correct code assignment

EXHIBIT A

71

CASE #1Stroke (#1)

UB-92

Principal Diagnosis

V57.89 Admission for rehabilitation with multiple therapies

Additional Diagnosis

438.21 Hemiplegia dominant/late effect CVA

438.12 Dysphasia as late effect of CVA

438.7 Visual disturbance late effect CVA

368.46 Homonymous hemianopsia

438.82 Dysphagia as late effect of prior oldstroke

V44.1 Gastrostomy status

Principal Procedure

96.6 Procedure: Tube feeding

72

CASE #2Stroke (#2)

A 75-year old right-handed female suffers acerebral infarction on the right side of her brainresulting in left-sided (non-dominant)hemiparesis, dysphagia (difficulty swallowing)and dysarthria (slurred speech).

EXHIBIT A


73

CASE #2Stroke (#2)

IRF-PAI

Impairment Group Code01.1 Stroke with left body involvement

Etiology

434.91 Cerebral infarction

Comorbid Conditions

787.2 Dysphagia

784.5 Dysarthria

74

CASE #2Stroke (#2)

UB-92

Principal Diagnosis



438.21 Hemiplegia affecting nondominant sideas late effect of cerebral infarction

438.82 Dysphagia as late effect of cerebralinfarction

438.19 Dysarthria/slurred speech as late effectof cerebral infarction


EXHIBIT A

75

CASE #3Non-traumatic Brain Dysfunction

This 62-year old female was independent until afew weeks prior to admission when shedeveloped difficulty ambulating. CT of the headshowed hydrocephalus and she was admitted tothe acute care hospital for placement of aventriculoperitoneal shunt. She is also treated forhypertension and acute renal failure which isresolving. She was transferred to the IRF toregain independence with bed mobility, transfers,

ambulation and self care.

76


IRF-PAI

Impairment Group Code

02.1 Non-traumatic brain dysfunction

Etiology

331.4 Communicating hydrocephalus

Comorbid Conditions

401.9 Hypertension

584.9 Acute renal failure

V45.2 Presence of cerebrospinal fluid drainage device

EXHIBIT A


77


UB-92

Principal Diagnosis



331.4 Communicating hydrocephalus

401.9 Hypertension

584.9 Acute renal failure

V45.2 Presence of cerebrospinal fluid drainage device

78


This is a 60-year old gentleman who sufferedanoxic brain damage as a complication duringhis coronary artery bypass procedure.


EXHIBIT A

79

CASE #4Brain Dysfunction

IRF-PAI

Impairment Group Code02.1 Non-traumatic brain dysfunction

Etiology

348.1 Anoxic brain damage

Comorbid Conditions

997.01 Postop central nervous system complication

414.00 Coronary atherosclerosis of unspecifiedtype of vessel, native, or graft

V45.81 Aortocoronary bypass status

80

CASE #4Brain Dysfunction

UB-92

Principal Diagnosis



997.01 Postop central nervous system complication

348.1 Anoxic brain damage

414.00 Coronary atherosclerosis of unspecifiedtype of vessel, native, or graft

V45.81 Aortocoronary bypass status

EXHIBIT A


81

CASE #5Traumatic Brain Dysfunction

This 45-year old male was in a motorcycle crashand was diagnosed with traumatic brain injuryand right tibial fracture. He had a tracheostomyplaced due to vent-dependent respiratory failure.He was weaned off the vent and transferred tothe IRF for rehabilitation of cognitive deficits andambulation dysfunction. During the IRF stay, thetracheostomy was removed.

82

CASE #5

Traumatic Brain Dysfunction

IRF-PAI


02.22 Closed Traumatic Brain Dysfunction

Etiology

854.00 Intracranial injury of other and unspecified nature without mention ofopen intracranial wound with unspecified loss of consciousness

Comorbid Conditions

310.1 Cognitive change due to conditions classified elsewhere

V55.0 Attention to tracheostomy

V54.16 Aftercare for healing traumatic fracture of lower leg


EXHIBIT A

83

CASE #5Traumatic Brain Dysfunction

UB-92

Principal Diagnosis



310.1 Cognitive change due to conditions classified elsewhere

907.0 Late effect of intracranial injury without mention of skull fracture

V55.0 Attention to tracheostomy


Procedure

97.37 Removal of tracheostomy tube

84

CASE #6Neurological Disorders

This is a 50-year old female who has beendiagnosed with Amyotrophic Lateral Sclerosis(a.k.a. Lou Gehrig’s Disease) and whose diseasehas progressed upward to the extent that she nowhas paralysis of both lower limbs. On admissionshe has a pulmonary infiltrate diagnosed in theacute hospital for which she is still on antibioticsand a cystostomy that is being attended to by thenursing staff.

EXHIBIT A


85


IRF-PAI

Impairment Group Code03.8 Other Neurologic

Etiology

335.20 Amyotrophic Lateral Sclerosis (ALS)a.k.a. Lou Gehrig’s disease

Comorbid Conditions

344.1 Paraplegia

V55.5 Attention to cystostomy

518.3 Pulmonary infiltrate (Tier 3)

86


UB-92

Principal Diagnosis



335.20 Amyotrophic Lateral Sclerosis (ALS)a.k.a. Lou Gehrig’s disease

344.1 Paraplegia

V55.5 Attention to cystostomy

518.3 Pulmonary infiltrate


EXHIBIT A

87

CASE #7Non-traumatic Spinal Cord Dysfunction

The 68-year old female was transferred to theIRF from the acute care facility with paraplegiafollowing surgical removal of metastatic diseasefrom the lumbar vertebrae. The patient had aright mastectomy to treat a breast malignancy inDecember 2005.

88


IRF-PAI


04.110 Paraplegia, unspecified

Etiology

198.5 Secondary malignant neoplasm of bone

Comorbid Conditions

V10.3 History of breast malignancy

V45.71 Acquired absence of breast

EXHIBIT A


89


UB-92

Principal Diagnosis



344.1 Paraplegia

V58.42 Aftercare following surgery for neoplasm

V10.3 History of breast malignancy

V45.71 Acquired absence of breast

90

CASE #8Non-traumatic Spinal Cord Injury

This is a 65-year old gentleman who has severelumbar degenerative disc disease with spinal cordimpingement and subsequent paraplegia who isafraid to have surgery due to a poor history ofhealing due to his advanced type 2 diabetes. Hisefforts in outpatient rehab have met with limitedsuccess. He is admitted now for multipletherapies under medical supervision as well ascontinued treatment for his diabetic neuropathyto maintain his muscle mass and to attempt torelieve his pain.


EXHIBIT A

91


IRF-PAI

Impairment Group Code04.110 Non-traumatic spinal cord with

paraplegia, unspecifiedEtiology

722.73 Lumbar DDD with myelopathy

Comorbid Conditions

250.60 Type 2 diabetes with neurologic manifestation

357.2 Polyneuropathy and diabetes

92


UB-92

Principal Diagnosis



722.73 Lumbar DDD with myelopathy

250.60 Type 2 diabetes with neurologic manifestation

357.2 Polyneuropathy and diabetes

344.1 Paraplegia

EXHIBIT A


93

CASE #9Traumatic Spinal Cord Dysfunction

This 45-year old male was transferred to the IRFfor rehabilitation of T-8 fracture with paraplegiafollowing a fall from a 2nd story porch. He has aneurogenic bladder and a history of hypoxia dueto sleep apnea.

94


IRF-PAI


04.210 Paraplegia, unspecified

Etiology

806.25 T-8 fracture with unspecified spinalcord injury

Comorbid Conditions

596.54 Neurogenic bladder

780.57 Sleep apnea

327.24 Sleep related hypoxia


EXHIBIT A

95


UB-92

Principal Diagnosis



344.1 Paraplegia

907.2 Late effect of spinal cord injury

596.54 Neurogenic bladder

780.57 Sleep apnea

327.24 Sleep related hypoxia

96

CASE #10Unilateral Knee Amputation

This is a 55-year old who was admitted followingan above the knee amputation due to type 2diabetic arteriosclerotic peripheral vasculardisease with gangrene. He also suffers fromdiabetic neuropathy.

EXHIBIT A


97

CASE #10Unilateral above the knee amputation

IRF-PAI

Impairment Group Code05.3 Unilateral above knee amputation (AKA)

Etiology

440.24 Arthrosclerosis of the extremities withgangrene

Comorbid Conditions

250.70 Type 2 diabetes with peripheral circulatory disorders

250.60 Type 2 diabetes with neurological manifestation

357.2 Polyneuropathy in diabetes

98

CASE #10Above the knee amputation

UB-92

Principal Diagnosis



V58.49 Other specified aftercare following surgery

V49.76 Status above knee amputation (AKA)

250.70 Type 2 diabetes with peripheral circulatory disorders

440.20 Arthrosclerosis of the extremities250.60 Type 2 diabetes with neurological

manifestation

357.2 Polyneuropathy in diabetes


EXHIBIT A

99

CASE #11Rheumatoid Arthritis

This is a 75-year old patient who suffers withrheumatoid arthritis complicated by morbidobesity. She has a history of a total hipreplacement in the past.

100


IRF-PAI

Impairment Group Code06.1 Rheumatoid Arthritis

Etiology

714.0 Rheumatoid Arthritis

Comorbid Conditions

278.01 Morbid obesity (Tier 3)

V43.64 Prosthetic hip joint

EXHIBIT A


101


UB-92

Principal Diagnosis



714.0 Rheumatoid Arthritis

278.01 Morbid obesity

V43.64 Prosthetic hip joint

102

CASE #12Osteoarthritis

This is a 75-year old female who suffers fromosteoarthritis of multiple sites (shoulders, hips,knees, fingers) who, due to her arthritis, is losingher mobility. She also suffers from a slowbleeding chronic stomach ulcer from years oftaking NSAIDS for her arthritis and as a resultalso has chronic blood loss anemia. She isadmitted now for multiple therapies to increaseher mobility and build up her strength whilereceiving medical supervision of her ulcer andanemia.


EXHIBIT A

103


IRF-PAI

Impairment Group Code06.2 Osteoarthritis

Etiology

715.89 Osteoarthritis involving multiple sites,not specified as generalized

Comorbid Conditions

531.40 Chronic stomach ulcer with hemorrhage(Tier 3)

280.0 Chronic blood loss anemia

104


UB-92

Principal Diagnosis



715.89 Osteoarthritis involving multiple sites,not specified as generalized

531.40 Chronic stomach ulcer with hemorrhage

280.0 Chronic blood loss anemia

EXHIBIT A


105

CASE #13Systemic Vasculidities

This is a 45-year old female who has suffered arecent exacerbation of her systemic lupuserythematosus. She also suffers from Raynaud’sdisease which has also been more of an issuerecently due to her increased stress over thisrecent flare up of her SLE.

106


IRF-PAI

Impairment Group Code06.9 Other Arthritis

Etiology

710.0 Systemic Lupus Erythematosus

Comorbid Conditions

443.0 Raynaud’s phenomenon


EXHIBIT A

107


UB-92

Principal Diagnosis



710.0 Systemic Lupus Erythematosus 443.0 Raynaud’s phenomenon

108

CASE #14Hip Fracture

This is a 85-year old gentleman who twisted hisleg and fell backwards while carrying out thegarbage. He suffered a subcapital hip fracturerequiring a hip replacement. His postoperativecourse was further complicated by a femoraldeep vein thrombosis for which he is undergoingtreatment as well while in rehab.

EXHIBIT A


109


IRF-PAI

Impairment Group Code08.11 Status Post Unilateral Hip Fracture

Etiology

820.09 Subcapital hip fracture

Comorbid Conditions

V43.64 Status prosthetic hip joint

453.41 Femoral deep vein thrombosis (DVT)(Tier 3)

110


UB-92

Principal Diagnosis



V54.81 Aftercare following joint replacement

V43.64 Status prosthetic hip joint

997.2 Postop peripheral vascular complication

453.41 Femoral deep vein thrombosis (DVT)


EXHIBIT A

111

CASE #15Multiple Fractures

This 76-year old male was an unrestrained driverin an automobile that hit a tree. He sustainedclosed fractures of the left tibia, left fibula andleft humerus. He has a history of hypertensionand COPD.

112


IRF-PAI


08.4 Major multiple fractures

Etiology

828.0 Multiple fractures involving lower withupper limb

Comorbid Conditions

496 COPD

401.9 Hypertension unspecified

EXHIBIT A


113


UB-92

Principal Diagnosis




V54.11 Healing traumatic fracture of upperarm

496 COPD

401.9 Hypertension

114

CASE #16Bilateral Knee Replacements

This 53-year old female has suffered for yearswith painful osteoarthritis in both knees. Shebegan to lose her mobility to the point thatbilateral knee replacements were her only option.Mary also has a history of combined systolic anddiastolic hear failure that flared up after surgeryfor which she is still receiving treatment.


EXHIBIT A

115


IRF-PAI

Bilateral Knee Replacements08.62 Status Post Bilateral Knee Replacements

Etiology

715.36 Osteoarthrosis, localized, not specifiedwhether primary or secondary, lower leg

Comorbid Conditions

428.40 Combined systolic and diastolic heartfailure, unspecified (Tier 3)

116


UB-92

Principal Diagnosis



V54.81 Aftercare following joint replacement

V43.65 Status prosthetic knee joint(s)

428.40 Combined systolic and diastolic heartfailure, unspecified

EXHIBIT A


117

CASE #17Burns

This 19-year old college student, sprayed hisaerosolized hair spray at a lit cigarette lighter.The ensuing large flame ignited his clothing. Hesuffered third degree burns on his hair, face,chest, trunk, right arm, and both legs. Hesuffered smoke inhalation from the subsequentfire in his dorm room and acute pulmonaryedema due to the fumes and vapors of the othermaterials burning in his room. Due to the smokeinhalation and burns he is also suffering from

dysphagia.

118

CASE #17Burns: Impairment Group 11

IRF-PAI

Impairment Group Code11 Burns

Etiology

948.53 Burns over 50% body; 30-39% of whichare third degree

Comorbid Conditions

946.3 Third-degree burns of multiple sites

987.9 Smoke inhalation

787.2 Dysphagia (Tier 2)

506.1 Acute Pulmonary Edema due to fumes/vapors (Tier 3)


EXHIBIT A

119

CASE #17Burns

UB-92

Principal Diagnosis



948.53 Burns over 50% of body surface, 30-39% of which are third-degree burns

946.3 Third-degree burns of multiple sites

987.9 Smoke inhalation

787.2 Dysphagia

506.1 Acute Pulmonary Edema due to fumes/vapors

E891.2 Hotel building fire

E849.6 Hotel

Principal Procedure

86.22 Surgical debridement

86.28 Nonexcisional debridement

120

CASE #18Congenital Deformities

This 14-year old was born with congenitalhemiplegic cerebral palsy which also resulted indysphagia. He has acquired contractures of bothhis lower left leg and left forearm. John also hasa urinary tract infection due to pseudomonas forwhich he is on antibiotic. John is admitted formultiple therapies as well as botox injections forhis contractures.

EXHIBIT A


121


IRF-PAI

Impairment Group Code12.9 Other Congenital Deformities

Etiology

343.1 Cerebral Palsy—hemiplegia

Comorbid Conditions

787.2 Dysphagia (Tier 2)

718.46 Acquired joint contracture—lower leg

718.43 Acquired joint contracture—forearm

599.0 UTI

041.7 Pseudomonas (Tier 2)

122


UB-92

Principal Diagnosis



343.1 Cerebral Palsy—hemiplegia

787.2 Dysphagia

718.46 Acquired joint contracture—lower leg

718.43 Acquired joint contracture—forearm

599.0 UTI

041.7 Pseudomonas

Principal Procedure

04.2 Botox injection


EXHIBIT A

123

CASE #19Major Multiple Trauma

This 56-year old was in a 2-car MVA in which hesuffered a closed head injury with subarachnoidhemorrhage and prolonged loss of consciousnesswith eventual return to his pre-existing state. Heis on antibiotics for aspiration pneumonia. He hashemiplegia, dysphagia, aphasia, and cognitivedeficits due to his head injury and is receivingaftercare for fractures of his hip, tibia and fibula.He has a tracheostomy and, although conscious,is stuporous or drowsy. He is admitted formultiple therapies and extensive acute rehab.

124

CASE #19Major Multiple Trauma: Brain & multiple fracturesImpairment Group: 14.2

IRF-PAI

Impairment Group Code14.2 Major Mult Trauma—Brain and Spinal Cord

Etiology

852.04 Closed head injury SAH/prolonged LOC and return to pre-existing state

Comorbid Conditions

342.90 Hemiplegia

787.2 Dysphagia

784.3 Aphasia

310.1 Cognitive deficit

507.0 Aspiration Pneumonia (Tier 3)

V54.13 Aftercare fx hip

V54.16 Aftercare fx tibia/fibula

V55.0 Attention to tracheostomy (Tier 1)

EXHIBIT A


125

CASE #19Major Multiple Trauma

UB-92

Principal Diagnosis



342.90 Hemiparesis

787.2 Dysphagia

310.1 Cognitive deficit

780.09 Drowsiness, stupor

907.0 Late effects of closed head injury

507.0 Aspiration Pneumonia (on meds)

V54.13 Aftercare of hip fracture

V54.16 Aftercare of fractured tibia/fibula

V55.0 Aftercare of tracheostomy

E929.0 Late effect of motor vehicle accident

Documents

CASE #1 Stroke (#1) - hcmarketplace.comhcmarketplace.com/supplemental/1213_CASE_STUDIES_ONLY.pdf · EXHIBIT A 38 Inpatient Rehabilitation Facility Coding and Billing: A team approach