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The “ostrich” approach will not work in this case, because ICD-10 is not going away. There is much to be done prior to implementation. Two different sets of ICD codes are required, one set for the IRF PAI, and another set for the UB-04.

Documentation Requirements:

The ICD-9-CM guidelines for assignment of codes for inpatient discharges by facilities paid under the Inpatient Rehabilitation Facility Prospective Payment System (IRF PPS) are different from the guidelines used for code assignment for discharges from hospitals paid under the DRG payment system. The IRF PAI reports a code for impairment, for example, and an ICD-9-CM code for the etiology of the impairment.

The UB-04 reports code V57.89, admission for multiple rehabilitation therapies, as a principal diagnosis. The principal diagnosis is not reported on the IRF PAI. Patients treated at IRFs receive initial care for injuries and diseases at an acute-care hospital, and coding guidelines require the assignment of codes representing late effects, aftercare or V codes to report conditions treated at the IRF. The codes for late effects and aftercare are not detailed, and limited information is required for code assignment. This will change with the implementation of ICD-10-CM, however, as the IRF PAI will require a detailed code for etiology, and co-morbid conditions will need to be reported. On the UB-04, the same code will need to be reported with a seventh ICD-10 character representing subsequent care or sequela, as a code comparable to V57.89 is not included in the ICD-10 classification.

Physician documentation will need to be more detailed going forward. For example, documentation that reports the etiology of hemiparesis as intracerebral bleeding will be insufficient. The coder will require documentation that provides information including:

  • Etiology: specific information on the cause of the impairment (hemorrhage, thrombosis, embolism, trauma);
  • Site-specific information, including the artery involved; and
  • Laterality.

Physician Education:

Currently, assigned codes representing the reason for an IRF admission or impairment (and the etiology of the impairment) are coded from the physician’s documentation, which is based on a review of documentation received from the acute-care hospital. This documentation could specify the specific etiology of the patient’s impairments, yet this information is not always abstracted and documented by the IRF physician.

If any coder is having difficulty assigning ICD-9-CM codes due to incomplete physician documentation, now is the time to start physician education. Coders often spend significant amounts of time trying to determine codes to assign using incomplete documentation, when the problem is the physician’s documentation, not the code assignment. Physicians will need to be queried, and if you start a query process now, things will be easier once ICD-10 is implemented.

Computer-Assisted Coding:

Will computer-assisted coding (CAC) be an option for your IRF? Although the unique requirements for code assignments are different from those in place for acute-care facilities, CAC software that reviews extensive documentation and provides suggested codes could save coders time in locating documentation requiring code assignment.

ICD-10 Education:

Is there a plan to educate staff in ancillary departments and therapists who currently report ICD-9-CM codes for their services? If so, who will provide the education? Will education be provided by current employees, or will an outside consultant who understands the unique requirements of code assignment for IRFs be required? Will the clinicians and therapists who report ICD-9-CM codes report their services with ICD-10 codes, or will the services be reported by coders?

Coding Assistance:

Will there be coders available who are educated in the IRF PPS requirements to supplement the coding staff when staff members receive ICD-10 coder education? Remember, during the implementation phase, code assignments could take additional time.

The following steps could be taken now:

  1. For each IGC, review the common etiology codes and the ICD-10 requirements to determine whether additional documentation will be required.
    1. Improve  physician documentation with a CDI program.
    2. Include information that will be required for ICD-10 in the physician queries.
  2. Review the benefits of computer-assisted coding to determine if it is right for your facility.
  3. Review the ICD-10-CM educational program for therapists and other ancillary departments.
  4. Review the need for coding assistance during ICD-10 training and during the implementation phase, and arrange for it if necessary.

About the Author

Patricia Trela, RHIA, is the director of HIM and rehabilitation services for Diskriter, Inc., a consulting firm offering integrated HIM rehabilitation consulting services, including HIM Interim management, IRF PPS compliance and education, coding and auditing support, dictation/transcription, and other solutions. She has more than 25 years of healthcare industry experience.  As a consultant, Pat has worked with many acute-care hospitals, rehabilitation hospitals and long-term acute-care hospitals (LTACH).  Pat facilitates the AHIMA Coding Physical Medicine Rehabilitation Community of Practice (COP). Pat is an AHIMA Approved ICD-10CM/PCS Trainer.

Contact the Author


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