Inpatient Rehabilitation – Coding Stroke Deficits on the IRF PAI & UB:04


By Nirmala Sivakumar, CCS, CDIP

This is a common error I see while doing audits of coding at Inpatient Rehabilitation Facilities.

Question:
How should deficits from a stroke be recorded on the IRF PAI? Do the codes differ on the UB:04?

Answer:
If the patient is admitted to inpatient rehabilitation following an acute stroke, the deficits from that stroke should be recorded with R codes (Chapter 18 of ICD-10-CM manual) on the IRF PAI. If patient presents with hemiparesis, G81.XX is recorded. The stroke resolves in acute care and it is the deficits that are being addressed in rehab, so they are recorded using acute codes.

For UB:04 coding, since IRF is considered post-acute care, the stroke deficits including hemiparesis will be recorded using Sequalae codes (Category I69, sequelae of cerebrovascular disease). Coders who also provide ICD-10-CM codes for the IRF-PAI must be aware of this and make sure they are giving accurate codes to the PPS coordinator.

 

Inpatient Rehab Coding
IRF-PPS coding guidelines differ from inpatient guidelines and can pose a challenge to even seasoned coders. IRF coding authority, Nirmala Sivakumar, CCS, CDIP, helps you to meet the challenge.

 

About the author

Nirmala Sivakumar, CCS, CDIP
Nirmala Sivakumar is an IRF Coding Educator based in PA. She has created and presented many webinars and workshops on IRF coding and improving clinical documentation. She has trained and mentored many rehab coders. She also has experience in conducting coding audits. She enjoys sharing her expertise and knowledge and has a desire to help coders and PPS Coordinators overcome the challenges of IRF PPS coding.

She has held previous positions as Health Information Management Supervisor for one of HealthSouth’s (Encompass) acute inpatient rehab hospital and as a HIM Coding Consultant at Uniform Data Systems for Medical Rehabilitation. She can be reached at [email protected] or visit www.irfcodingexplained.com.

Disclaimer: This article is written for educational purposes only. Every reasonable effort has been made to ensure its accuracy and completeness. It is the responsibility of the reader to refer to the definitions, descriptions, conventions, and guidelines specific to each coding classification, as well as relevant laws and regulations when selecting and reporting medical codes.

About the Author

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