Eli's Rehab Report

Published on Wed Apr 06, 2005 PDF

Hint: Reporting E codes may push your claims through faster

As baseball, tennis, and golf get into full swing, your sports medicine rehabilitation practice can expect to see an influx of various injuries such as shoulder bursitis, rotator cuff tear, epicondylitis, contusions, and ligament tears.
 
Stay ahead of the game by knowing what to do when a referring physician and therapist's diagnosis codes differ and how E codes can streamline your claims.

Tip: Don't Strike Out Referral Reason

When you're securing medical necessity for sports therapy services, you should keep in mind that your physical therapist's treatment diagnosis may slightly differ from a referring physician's medical diagnosis - but each diagnosis should still relate to one another.

Scenario: Let's say a patient falls while playing Frisbee in the park and hurt his right shoulder. He presents to his primary care physician, who performs an E/M service and refers him to your physical therapist (PT). The PCP diagnoses the patient as having shoulder bursitis (726.10, Disorders of bursae and tendons in shoulder region, unspecified).  But after the PT examines the patient he diagnoses him as having a rotator cuff tear (840.4, Sprains and strains of the shoulder and upper arm; rotator cuff [capsule]), offers Karen Martin, CPC, administrative director of Boulder Center for Sports Medicine in Boulder, Colo. How should you handle the PCP's initial diagnosis code, should you discard it entirely or keep it in your report?

When your therapist drafts his plan of care, he should reference the reason for the referral as the medical diagnosis, in this case, shoulder bursitis (726.10 ). The therapist should also document his findings as the treatment diagnosis, the condition(s) he will treat by therapeutic interventions. In this case, the treatment diagnosis is rotator cuff tear (840.4).

These two diagnoses may be different, but they should always relate to the reason for referral, says Carl Byron, ATC-L, EMT-I, CPC, principal of Health Care Consulting Services Inc. in Hickory, N.C. Note that while the therapist's treatment diagnosis differs from the PCP's medical diagnosis, the two show consistency with respect to the area in question (the patient's shoulder).

Important: If you've got a question about the patient's medical diagnosis, contact the referring physician and ask for his or her input, recommends K. Scott Malone, MD, a physiatrist at Houston Orthopedic Surgery and Sports Medicine Clinic in Warner Robins, Ga.

Tip 2: Beat the Clock With E Codes

You know that you can only use an external code, or E code, as an additional code that's sequenced last, after other treatment codes, but what you may not realize is that these E codes can accelerate the speed at which the carrier processes your claim.

If the patient suffers from an acute injury, payers have a date on the 1500 form in box 14 and will likely hold the claim while looking for another primary payer. Therapists may use E codes rarely, but it's important to be aware of them because some types of injuries may appear to qualify a patient for workers' compensation when they actually do not, and E codes can clarify the circumstances for the payer, says Joanne Byron, LPN, BSNH, CPC, CHA, president of Health Care Consulting Services Inc. in Hickory, N.C.

Keep in mind: Check with your payers to see whether they accept E codes before including them on your claim.

Example 1: Score With Tennis Elbow

A golfing enthusiast has inflammation of the wrist extensors at their origin, which is the lateral epicondyle of the elbow. This condition is known as "tennis elbow" or "golfer's elbow," and you should code it using 726.32 (Lateral epicondylitis).

Other injuries that might temporarily delay a spring sports athlete's game are medial epicondylitis (726.31), enthesopathy of elbow (726.30), and olecranon bursitis (726.33). Remember, enthesopathies refer to disorders of peripheral ligamentous or muscular attachments.

Heads up: You're likely to report codes for pain relief and inflammation reduction using ice (97010, Application of a modality to one or more areas; hot or cold packs) or muscle strengthening and stretching exercises such as:

97110 - Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility
97140 - Manual therapy techniques (e.g., mobilization/manipulation, manual lymphatic drainage, manual traction), one or more regions, each 15 minutes
97150 - Therapeutic procedure(s), group (2 or more individuals)

Example 2: Clobber Contusion Confusion

A baseball player presents with a contusion from a wildly thrown ball. In order to choose the correct diagnosis code for this scenario, you need to answer two questions: 

1) Is the skin intact?

2) Where is the contusion?

If the skin is intact, you choose a code in the 920.x - 924.x (Contusion with intact skin surface) category, which includes bruising and/or hematomas. The fourth and fifth digits, however, are determined the anatomic site.
 
If the contusion is to the patient's arm, then you have multiple coding options: (1) the lower arm, which includes the forearm, using 923.10, (2) the upper arm using 923.03, and (3) the shoulder and axillary region using 923.09 (Multiple sites).
 
Keep in mind: If the contusion coincides with another injury, then you should look at other conditions such as crush, dislocation, fracture, injury (nerve) or wound (open) in your ICD-9 book, C. Byron recommends.

Example 3: Ace Ligament ICD-9 Coding

An avid tennis player tears her ACL and presents to your PT for therapy. The diagnosis code you should link to your therapy service codes is 844.2 (Sprains and strains of the knee and leg; cruciate ligament of knee).

Caution: When you are searching for ICD-9 codes for ligament injuries, don't search by term "ligament" in the alphabetical index. Instead, you should search for ligament tears using the keyword "sprain" by site.

Knee ligaments, particularly the ACL, are vulnerable to injuries caused by excessive twisting, or rotation. At the same time, the meniscus cartilage between the femur and the tibia is prone to compression, fraying, and tears by trauma. For a current tear of meniscus, you should report 836.0 (Tear of medial cartilage or meniscus of knee, current) or 836.1 (Tear of lateral cartilage or meniscus of knee, current) depending on the documentation of the injury.

(Editor's Note: For a free chart listing common sports injuries ICD-9 codes, contact me at suzannel@eliresearch.com)