Comprehensive Tier Diagnosis & Practice Scenarios

Extensive diagnosis lists, comorbid conditions, and real-world coding scenarios for Tiers 1, 2, and 3

Understanding Tier Assignment Through Real Examples

This comprehensive guide provides extensive lists of diagnoses and comorbid conditions that fall into each tier category, along with detailed practice scenarios showing exactly how to code tier assignments. Understanding these patterns is critical for accurate IRF-PAI completion and maximizing appropriate reimbursement while maintaining compliance.

What You'll Learn:

  • • Complete lists of common comorbid conditions for each tier
  • • Specific ICD-10 codes and their tier implications
  • • 20+ detailed practice scenarios with step-by-step coding rationale
  • • How to identify "actively treated" vs. inactive conditions
  • • Common coding pitfalls and how to avoid them

TIER 1: No/Minimal Comorbidity

0-1 qualifying comorbidities

Common Tier 1 Scenarios:

Tier 1 patients typically have a single primary rehabilitation diagnosis with either NO comorbidities or only ONE non-complex comorbidity that is actively treated.

Zero Comorbidities:

  • • Stroke patient with no other active conditions
  • • Hip fracture patient, otherwise healthy
  • • Knee replacement with no complications
  • • Brain injury patient with no pre-existing conditions

One Non-Complex Comorbidity:

  • • Stroke + controlled hypertension only
  • • Hip fracture + hypothyroidism only
  • • Spinal cord injury + depression only
  • • Joint replacement + osteoporosis only

Typical Tier 1 Comorbidities (When Present as Single Condition):

Cardiovascular:

  • • Hypertension (I10)
  • • Hyperlipidemia (E78.5)

Endocrine:

  • • Hypothyroidism (E03.9)
  • • Type 2 DM without complications (E11.9)

Musculoskeletal/Other:

  • • Osteoporosis (M81.0)
  • • Depression (F32.9)
  • • Anxiety (F41.9)

Tier 1 Practice Scenarios:

TIER 2: Moderate Comorbidity

1-2 qualifying comorbidities OR high-impact condition

Common Tier 2 Scenarios:

Tier 2 patients have EITHER 1-2 qualifying comorbidities OR specific high-impact conditions that automatically qualify for Tier 2 regardless of comorbidity count.

1-2 Comorbidities:

  • • Stroke + CHF + COPD (2 comorbidities)
  • • Hip fracture + diabetes + hypertension (2 comorbidities)
  • • Brain injury + depression + anemia (2 comorbidities)

High-Impact Conditions (Auto-Tier 2):

  • • Hemiplegia/hemiparesis (G81.x)
  • • Paraplegia (G82.2x)
  • • Quadriplegia (G82.5x)
  • • Obesity BMI ≥40 (E66.01)
  • • Morbid obesity with hypoventilation (E66.2)

Common Tier 2 Comorbidity Combinations:

Cardiovascular Pairs:

  • • CHF (I50.x) + Hypertension (I10)
  • • CAD (I25.x) + Atrial fibrillation (I48.x)
  • • CHF (I50.x) + CAD (I25.x)
  • • COPD (J44.x) + CHF (I50.x)

Mixed Condition Pairs:

  • • Diabetes with complications (E11.x) + CKD (N18.x)
  • • COPD (J44.x) + Diabetes (E11.x)
  • • Anemia (D64.x) + CHF (I50.x)
  • • Depression (F32.x) + Diabetes (E11.x)

Tier 2 Practice Scenarios:

TIER 3: High Comorbidity

3 or more qualifying comorbidities

Common Tier 3 Scenarios:

Tier 3 patients have 3 OR MORE qualifying comorbidities that require intensive medical management during the IRF stay. These are medically complex patients with multiple active conditions.

Three Comorbidities:

  • • Stroke + CHF + COPD + Diabetes (4 total)
  • • Hip fracture + CKD + Anemia + CAD (4 total)
  • • Brain injury + Depression + Diabetes + HTN (4 total)

Complex Medical Patients:

  • • Multiple organ system involvement
  • • Requires intensive medical monitoring
  • • Multiple medication regimens
  • • Frequent lab monitoring needed

Common Tier 3 Comorbidity Combinations:

Cardiopulmonary Cluster:

  • • CHF + COPD + CAD
  • • CHF + Atrial fib + Hypertension + COPD
  • • CAD + CHF + Diabetes + CKD

Metabolic/Renal Cluster:

  • • Diabetes + CKD Stage 4 + Anemia + CHF
  • • CKD + Diabetes + Hypertension + CAD
  • • Diabetes + CHF + COPD + Depression

Tier 3 Practice Scenarios:

Key Takeaways for Tier Coding

Tier 1 Criteria:

  • • 0-1 comorbidities
  • • Single non-complex condition
  • • Minimal medical management
  • • Otherwise healthy patients

Tier 2 Criteria:

  • • 1-2 comorbidities, OR
  • • High-impact condition present
  • • Moderate medical management
  • • Check for auto-qualifiers

Tier 3 Criteria:

  • • 3+ comorbidities
  • • Medically complex patients
  • • Intensive medical management
  • • Multiple organ systems involved