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Monthly CDI Scenario Discussion – February 2020

Topic: Functional Quadriplegia


  • 72 year old male admitted from a skilled nursing facility with complaints of uncontrolled blood pressure by SNF staff. PMH of severe Alzheimer’s dementia, CAD, HTN, CKD3 with baseline creatinine of 1.5
  • Per H&P: SNF staff reported difficulty controlling blood pressure over the last 24 hours. BP at SNF reported to be >220/100. BP since arrival to the hospital has consistently been greater than 190/120. Pt. was noted to be clinching his chest and admits to chest pain. Nitroglycerin gtt started urgently in ED with continuation upon admission. Physical exam notes the following: bilateral leg contractures, pt. is disoriented to person, place, time and situations which is his baseline. Social history of the H&P notes pt. is bedridden requiring total assist at SNF.
  • Admission work-up noted on GFR of 31, Creatinine 1.7, troponins negative, and EKG without acute ischemic changes. Admitting Diagnosis: Accelerated HTN-Plan for cardiology consult and further work-up.
  • Cardiology Consult: Malignant HTN with complaints of chest pain. PMH of CAD, Echo demonstrated preserved EF without wall motion abnormality. Cardiac Cath Report: Mild CAD, chest pain likely due to malignant HTN. Continue current therapy.
  • Nursing assessment: Braden Scale
    • Mobility: completely immobile
    • Activity: bedridden
    • Plan: turn q 2 hours and float heels while in bed
  • Physical therapy evaluation notes maximum assistance with transfers and positioning, patient has not walked in years per SNF paperwork. Occupational therapy evaluation notes patient needs maximum assistance with all ADLs.

Question: Are there any query opportunities based on the scenario stated above?

Discussion: Patient presented with indicators of Functional Quadriplegia and uncontrolled blood pressure that needs clarification based on the information provided.

R53.2Functional QuadriplegiaInability to use one’s limbs and ambulate due to extreme debility or frailty by another medical condition without physical injury or damage to the spinal cordMCC/HCC
I16.0Hypertensive UrgencyBP is elevated to 180 or higher for the systolic or 110 or higher forthe diastolic pressure, without associated organ damageNone
I16.1Hypertensive EmergencyThe BP elevations occur (exceeding 180/110) but the hypertension is always accompanied by symptoms of organ damage.CC
I16.9Hypertensive Crisis, unspecifiedA severe increase in blood pressure that can lead to a stroke.CC

UASI Recommendations:

  • Query for Functional Quadriplegia
  • Query for HTN specificity

Documentation without Clarification:

  • Principal Diagnosis: Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease (I129); CKD 3 (N183)
  • Secondary Diagnosis: Alzheimer’s Dementia (G309), (F0280), CAD (I2510)
  • Procedure: Left Heart Cath (4A023N7)

DRG 684 Renal Failure without CC/MCC

RW=0.6153, FMLOS 2.2, SOI/ROM 1/2

Documentation with Clarification:

  • Principal Diagnosis: Hypertensive urgency (I160)
  • Secondary Diagnosis: Alzheimer’s dementia (G309) (F0280), CAD (I2510), Hypertensive chronic kidney disease with stage 1 through stage 4 chronic kidney disease, or unspecified chronic kidney disease (I129), CKD3 (N183), Functional Quadriplegia (R532)
  • Procedure: Left Heart Cath (4A023N7)

DRG 286 Criculatory Disorders except AMI, with Card Cath W MCC RW=2.1974, CMLOS 5.2, SOI/ROM 2/2

CDI Educational Tips:

Quadriplegia TipsQuadriplegia Common Causes
Review ADLs for a high degree of disability. Key words to review include complete immobility, max/total assist, bedridden or non-ambulatory, not simply “needs assistance”Severe or end stage dementia
Flexion contractures noted in physical assessmentProgressive neuro-degenerative disorders (i.e., ALS, MS, Huntington’s)
Require assistance with feeding and groomingSevere brain damage
Urinary/fecal incontinence is common, may have indwelling devices presentSevere arthritis or advance musculoskeletal deformity
Braden scores with mobility=1 (completely immobile) or 2 (very limited) & activity=1 (bedridden)Profound intellectual disability
Order: Q2 hour turns with heels floated
  • Query for hypertensive urgency or emergency when the nonspecific term “crisis” is used and relevant BP measurements are documented.
  • Query for associated organ damage based on diagnostic indicators when hypertensive emergency is documented

This is a short synopsis of a possible patient record and is not intented to be all inclusive. This is for educational purposes only and not intended to replace your institutional guidelines.