Coding Guidelines

Jacoder

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A few months ago our facility started offering Physical Therapy. One of the problems I have been running into is where the diagnoses are coming from. The person over PT (contract worker) will give me the MD order and a refferal sheet with additional diagnoses determined by the certified Physical Therapist. In some cases when I call her for a DX (because there isn't one on the order) she will give me one that PT determined. I was always under the impression that I cannot code from anything other than that which has been asigned by a physician. You know, the person has to have MD or PA after their name.

I thought it would be easy to find some kind of guideline to back this up, but I haven't found anything. Is it true that we can ONLY code from a Dr or PA's work? And where can I find this in writing? Thanks!
 

mitchellde

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The first listed dx for visits in any setting when the reason for the visit is rehab will V57.xx after that the reason for rehab is secondary. I have run into this issue so many times.. many time the therapist gets a order for something like "hip fx needs rehab". then they must go thru the analysys to determine what exactly is required. I tell them they need a V57.xx first then the reason for rehab like instability then a late effect code such as 905.x . If you look at A-B-01-144 from 2001 you get a little glimmer of I think what you are wanting. It talks about what constitues an order for services, now it centers on xrays and such but I think we can stretch it further, to include this, but at one point it states when all else fails then the person delivering the ancillary service can "ask the patient" why they are there. As long as every effort is made to verify the information with the physician office. I know that a PT cannot render a diagnosis, but they can use what they have to be more specific about pain and stiffness and such.
 

Jacoder

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Debra,

Thanks for the response! I'm aware of the V57.XX code and I do use it. What you said does make this a little clearer. Here's my scenerio, tell me if I'm wrong.

Patient comes to PT for "CVA: 434.91" as diagnosed by the Dr. When Medicare denied it for lack of medical necessity I called PT to see if the patient has right or left sided weakness, hoping this will help. Durring the phone call she told me to use "Abnormalty of Gait." Okay, I know the patient may have abnormal gait, but the Dr didn't diagnose that. Can I code it?
 
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mitchellde

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As long as you verify with the physician office. Abnormality of gait is what the PT observed and should be documented in their record. You cannot use an acute CVA code once the acute event is past. The 434.91 is a code for the acute CVA and is not medical necessity for PT. You need as your secondary code the appropriate 438.xx code for the late effect of the CVA that warrents PT.
 
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