Radiology Coding Alert

Question: The indication states that the patient is unable to move his upper limbs, but the patient has no history of neurological disorder. Additionally, the brain scan did not reveal any significant findings. Should I code this as functional quadriplegia?

California Subscriber

Answer: This question offers a great example of why you should always keep your coding manuals up to date. Before the 2018 ICD-10-CM manual was published, the answer to this question would have been no. ICD-10-CM used to instruct you to only code as R53.2 (Functional quadriplegia) if the report specifically stated “functional quadriplegia.” However, as you can see in the 2018 guidelines, the ICD-10-CM manual removed the guidelines specific to functional quadriplegia coding.

Therefore, you should rely exclusively on the index to direct you to the correct code. In the case of the indicating diagnosis, you can search under Immobile, immobility ⇒ complete, due to severe physical disability or frailty which leads you to R53.2.