Clarification Related to Active Diagnoses, Quadriplegia and Acceptable Physician Documentation of Diagnoses

At the February 14, 2013, Open Door Forum (ODF), CMS staff provided clarification regarding active diagnoses. CMS indicated only active, physician-documented diagnoses are coded on the MDS. Diagnoses listed in section I are only those most problematic for the long-term care population. There are many diagnoses that are not listed in section I. Active diagnoses that are not listed in section I should be coded in item I8000.

CMS indicated a diagnosis of functional quadriplegia cannot be coded in item I5100, quadriplegia. Item I5100, quadriplegia, "primarily refers to the paralysis of all four limbs (arms/legs) caused by spinal cord injury, period." CMS further indicated functional quadriplegia "refers to complete immobility due to severe physical disability or frailty." Conditions such as cerebral palsy, stroke, pressure ulcers, contractures, advanced dementia, etc. can also cause functional paralysis that may extend to all limbs hence, the diagnosis functional quadriplegia. For individuals with these types of severe physical disabilities, where there is minimal ability for purposeful movement, their primary physician-documented diagnosis should be coded on the MDS and the resulting paralysis from that condition should not be coded on the MDS. For example, an individual with cerebral palsy with spastic quadriplegia should be coded in item I4400, cerebral palsy, and not in item I5100, quadriplegia. A diagnosis of functional quadriplegia should be coded only in item I8000. If we receive further clarifications regarding this item, we will post them on this website.

Subsequent to the ODF, CMS was asked if the care plan identifies a diagnosis and the signed, physician orders indicate the physician has reviewed the plan of care, does this meet the criteria of a physician-documented diagnosis provided the physician's orders were signed within 60 days of the ARD? They responded, "No, it has to be a physician-documented diagnosis."

Case Mix Review staff will immediately implement these clarifications in the audit and reconsideration processes.

Please direct questions related to this clarification to: