Eli's Rehab Report

Published on Wed Apr 24, 2013 PDF

Question: Our new home health patient has difficulty ambulating and weakness due to her lumbosacral spondylosis, lumbar spinal stenosis, and osteoarthritis. She also has type 2 diabetes and is insulin-dependent. Additional diagnoses include peripheral neuropathy, and hypertension.

We are providing physical therapy for strength training, gait training, and to improve safety. The patient needs reminding to use her walker for gait stability. She is at high risk for falling. She has chronic back pain and joint aches. Nursing was not ordered.

How should we code for this patient?

Answer: List the following codes for your patient:

·         M1020a: V57.1 (Other physical therapy);

·         M1022b: 721.3 (Lumbosacral spondylosis without myelopathy);

·         M1022c: 724.02 (Spinal stenosis; lumbar region, without neurogenic claudication);

·         M1022d: 715.90 (Osteoarthrosis, unspecified whether generalized or localized; site unspecified);

·         M1022e: 356.9 (Hereditary and idiopathic peripheral neuropathy; unspecified); and

·         M1022f: V15.88 (History of fall).

Other pertinent diagnoses: 250.00 (Diabetes mellitus without mention of complication; type II or unspecified type, not stated as uncontrolled) and 401.9 (Essential hypertension; unspecified).

You’ll list V57.1 in M1020a because this is a therapy-only case. Follow this with the conditions physical therapy is caring for — in this scenario, the patient’s lumbosacral spondylosis, lumbar spinal stenosis, and osteoarthritis.

Tip: List 715.90 for osteoarthrosis if the affected joint isn’t identified. If multiple joints are affected, use 715.89 (Osteoarthrosis involving, or with mention of more than one site, but not specified as generalized).

Next, list the code for your patient’s peripheral neuropathy, 356.9. This condition includes weakness as a symptom, so there’s no need to code weakness separately. Remember, it’s not appropriate to list symptom codes when you have a definitive diagnosis.

Also: In this example, the neuropathy isn’t documented as a symptom of diabetes, so you can’t code for it as such even though the patient also has diabetes.

Your patient’s diabetes and hypertension diagnoses didn’t make it to the top six slots of the code list. If the therapist is addressing these conditions in the care plan, you can list them as “Other pertinent diagnoses.”