I5100: Quadriplegia, Step-by-Step
Step-by-Step Coding Guide for I5100: Quadriplegia
1. Review of Medical Records
Objective: Confirm if the resident has a documented diagnosis of quadriplegia resulting from a spinal cord injury.
Actions:
- Review physician notes, hospital discharge summaries, and progress notes to confirm that quadriplegia is a result of a spinal cord injury and is actively affecting the resident's function.
- Verify that quadriplegia is documented as the cause of paralysis in all four limbs (arms and legs).
2. Understanding Definitions
I5100: Quadriplegia: Quadriplegia refers to the paralysis of all four limbs (arms and legs) caused by spinal cord injury. It should only be coded when the quadriplegia is a direct result of spinal cord injury and not due to other conditions, such as cerebral palsy, brain disease, or severe contractures.
- Functional Quadriplegia: Refers to immobility due to severe disability or frailty, but it should not be coded under I5100 unless caused by spinal cord injury. For conditions such as cerebral palsy, the primary diagnosis (e.g., cerebral palsy) should be coded instead.
Illustration 1:
Scenario: A resident was injured in a car accident, resulting in spinal cord damage and paralysis of both arms and legs.
Result: I5100 is coded "Yes", as the resident’s quadriplegia is due to spinal cord injury.
3. Coding Instructions
Step-by-Step:
- Step 1: Review the medical records for documentation of quadriplegia due to a spinal cord injury.
- Step 2: Ensure that the paralysis affects all four limbs.
- Step 3: If quadriplegia is confirmed, mark I5100 as "Yes".
- Step 4: If the resident’s paralysis is due to other conditions (e.g., brain injury, cerebral palsy), mark "No" and code the primary diagnosis accordingly.
Illustration 2:
Scenario: A resident with advanced dementia is immobile and unable to move their limbs, but there is no spinal cord injury.
Result: I5100 is coded "No", as the immobility is due to dementia, not a spinal cord injury.
4. Coding Tips
- Do Not Misclassify: Ensure that the condition being coded as quadriplegia results directly from spinal cord injury and not from conditions like brain injury, advanced dementia, or cerebral palsy.
- Check Diagnosis Source: The physician should clearly document that the quadriplegia is caused by a spinal cord injury.
5. Documentation
Objective: Ensure that quadriplegia is clearly documented as a result of spinal cord injury.
Actions:
- Record the underlying cause of the quadriplegia, emphasizing that it results from a spinal cord injury.
- Include any relevant treatment or therapies that address the resident’s quadriplegia.
Illustration 3:
Scenario: A resident’s chart includes a history of a spinal cord injury that led to quadriplegia and documents the ongoing need for mobility aids and assistance with daily living.
Documentation: Ensure the documentation is complete, and code I5100 appropriately.
6. Common Errors to Avoid
- Coding Functional Quadriplegia: Do not code I5100 for residents with paralysis due to conditions like cerebral palsy, brain disease, or advanced dementia. Instead, code the primary diagnosis (e.g., cerebral palsy or dementia).
- Missing Spinal Cord Injury: Ensure that quadriplegia is only coded if it is explicitly linked to a spinal cord injury.
Illustration 4:
Scenario: A resident has severe cerebral palsy and is quadriplegic but has no spinal cord injury.
Error: Do not code I5100 in this case; the correct code would be for cerebral palsy.
7. Practical Application
- Example 1: A resident was injured in a fall and suffered a spinal cord injury, resulting in quadriplegia. I5100 is coded "Yes".
- Example 2: A resident has paralysis due to multiple sclerosis but no spinal cord injury. I5100 is coded "No".
Please note that the information provided in this guide for MDS 3.0 Item set I5100 was originally based on the CMS's RAI Version 3.0 Manual, October 2023 edition. Every effort will be made to update it to the most current version. The MDS 3.0 Manual is typically updated every October. If there are no changes to the Item Set, there will be no changes to this guide. This guidance is intended to assist healthcare professionals, particularly new nurses or MDS coordinators, in understanding and applying the correct coding procedures for this specific item within MDS 3.0.
The guide is not a substitute for professional judgment or the facility’s policies. It is crucial to stay updated with any changes or updates in the MDS 3.0 manual or relevant CMS regulations. The guide does not cover all potential scenarios and should not be used as a sole resource for MDS 3.0 coding.
Additionally, this guide refrains from handling personal patient data and does not provide medical or legal advice. Users are responsible for ensuring compliance with all applicable laws and regulations in their respective practices.
