Eli's Rehab Report

Published on Thu Sep 24, 2009 PDF

Question: I want to make sure we're billing our diagnosis codes to Medicare compliantly. So, what is the standard with coding charts for billing? Is it okay to use the "abnormality of gait" code for billing if the doctor has signed a plan of care that lists the abnormality of gait? Is there strict use of the diagnosis code that the doctor provides (i.e. on the script) throughout all documentation? Is it acceptable for a therapist to note a "treatment diagnosis" on the plan of care -- one more specific to the patient's condition being addressed by the therapy (i.e. the patient is referred for "CVA," and the PT documents "Abnormality of gait" under treatment diagnosis)?

-- Georgia subscriber

Answer: The best thing you can do is to bill the most relevant diagnosis. That is, find the ICD-9 code that best describes the reason for treatment and put that on the claim form. In the Medicare Claims Processing Manual (CMS Pub 100-04), Section 10.2 of the outpatient therapy billing manual, CMS offers the following example: When a patient with diabetes is getting therapy treatment for gait training due to an amputation, the preferred diagnosis is abnormality of gait (which characterizes the treatment).

CMS goes on to say, "When possible in accordance with state and local laws and the contractor's local coverage determinations, avoid using vague or general diagnoses. When a claim includes several types of services, or where the physician/NPP must supply the diagnosis, it may not be possible to use the most relevant therapy code in the primary position. In that case, the relevant code should, if possible, be on the claim in another position."

Example: Suppose a patient who has suffered a CVA is getting physical therapy for ataxia (781.3), occupational therapy for hemiparesis affecting her dominant side (438.21), and speech therapy for oral phase dysphagia (787.21). You would put the CVA diagnosis (436) in the primary position and list the other three diagnosis codes afterward. (For dysphagia, you'd also list 438.82 -- dysphagia due to late effect of cerebrovascular accident.)

To read the full text, scroll to page 14 at: www.cms.hhs.gov/manuals/downloads/clm104c05.pdf.