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Medical Record
Patient: John Smith
**Admission Date:** 01/15/2025 **Primary Diagnosis:** Left CVA (Cerebrovascular Accident) with right hemiparesis **ICD-10 Code:** I63.9 **History:** 68-year-old male admitted from acute care hospital following ischemic stroke 5 days ago. Patient presents with moderate right-sided weakness affecting upper and lower extremities. Requires moderate assistance with ADLs. Alert and oriented x3. Speech mildly slurred but comprehensible. **Therapy Needs:** PT, OT, and ST recommended. Patient is medically stable and able to participate in 3 hours of therapy daily. **Comorbidities:** Hypertension, Type 2 Diabetes **Pre-admission Living Situation:** Home with spouse
IRF-PAI Coding
Complete the admission IRF-PAI based on the medical record
Coding Tips
- • Always verify the primary diagnosis matches the physician's documentation
- • Ensure the IGC code corresponds to the CMS-13 list for 60% Rule compliance
- • Double-check admission dates against the medical record
- • Count comorbidities carefully to determine the correct RIC tier
- • When in doubt, consult the IRF-PAI Manual Chapter 2 for item-by-item guidance