Clinically Speaking: Check CDI efforts related to functional quadriplegia

Association of Clinical Documentation Improvement Specialists, January 1, 2016

by Richard D. Pinson, MD, FACP, CCS
Quadriplegia is a very familiar condition that would never go unnoticed and undocumented in the medical record. The causes are typically catastrophic damage to the upper spinal cord due to trauma, vascular injury, or neoplasm. It could be described as structural or spinal quadriplegia to distinguish it from functional quadriplegia.
Functional quadriplegia, however, is defined as the inability to move due to severe disability or frailty caused by another medical condition without physical injury or damage to the spinal cord. It is comparable to spinal quadriplegia in its consequences because patients require total (or near-total) care. The effect of functional quadriplegia on intensity and complexity of care, severity of illness, and costs of care is equivalent in every respect to spinal quadriplegia.
The most common cause of functional quadriplegia is advanced brain and/or neuromuscular degeneration from such things as dementia, hypoxic or traumatic brain injury, multiple sclerosis, amyotrophic lateral sclerosis (ALS), Huntington’s disease, profound intellectual/ mental disability, and similar conditions. Some birth defects or advanced musculoskeletal deformity, including severe, progressive arthritis, may result in functional quadriplegia. Most, but by no means all, patients with this condition exhibit extreme cognitive and mental disability.
Common consequences of functional quadriplegia are pressure ulcers, flexion contractures, recurrent aspiration, malnutrition, alimentation support (including G-tube feeding), urinary and fecal incontinence, and catheter drainage of the bladder.
The Braden Scale, assessed by nurses and used to predict the risk of developing pressure ulcers, has two objective indicators useful for recognizing and confirming functional quadriplegia with additional subsets, such as:
Activity and mobility:
  •  Mobility
    • Completely immobile
    • Very limited
  • Activity
    • 1 - Bedfast
Likewise, nursing assessments of the basic activities of daily living (ADL) will indicate a high degree of disability or dependence for such measures as:
  • Communication
  • Ambulation
  • Transferring
  • Dressing
  • Eating
  • Swallowing
  • Toileting
  • Bathing
An assessment of simply “needs assistance” does not support a diagnosis of functional quadriplegia.
In order to explain functional quadriplegia to physicians, CDI specialists first need to acknowledge that the term itself does not originate from clinical sources but from the ICD-10-CM coding classification system to provide a code that describes the debilitating nature and severity of non-spinal quadriplegia—a condition which requires almost total care of the individual suffering from it.
Some neurologists use the term functional quadriplegia to describe patients who, for emotional or other reasons, pretend to be paralyzed. They may describe patients who require total care for non-spinal reasons as quadriparetic even though quadriparesis has historically been used for patients with spinal injury. Either term allows code assignment to accurately portray the patient’s condition.
From a coding perspective, spinal quadriplegia and functional quadriplegia are both considered serious comorbid conditions that contribute substantially to the severity of illness, complexity of care, and hospital reimbursement for the costs of caring for such patients. Imagine the intensity of nursing care, monitoring, and length of stay required in these circumstances. Both functional quadriplegia (complete paralysis) and functional quadriparesis (partial paralysis) are coded as the same condition; this code, R53.2, is an MCC in MS-DRGs and has a severity of illness of 3 in APR-DRGs.
In summary, look for patients who require total or near-total care in association with profound, advanced, debilitating medical conditions. Identify physical findings that are characteristic of functional quadriplegia and comorbidity commonly associated with it. Verify by reviewing nursing records of the Braden Scale and ADLs that provide objective evidence of extreme disability and functional impairment.
Editor’s note: Pinson is a physician, educator, and healthcare consultant. He practiced internal and emergency medicine for 25 years, and has trained thousands of physicians and other healthcare professionals nationwide. He is the co-author of the best-selling CDI Pocket Guide and the CDI for the Clinician™ e-learning training solution, and writes for the American College of Physicians’ Hospitalist magazine.