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.