Wiki Long term care (SNF) therapy coding

[JWBockrath]

Does anyone have any experience coding in long term care for rehab/therapy? I am the Director of Rehab and one year AAPC coder! We are working on ICD-10 transition and have questions on what the difference in documentation needs to be in place for contracture of joint vs contracture of muscle vs joint stiffness.

thanks!

 

[karinlouk]

We do some therapy coding at my facility. Documentation should include where the contracture is (as specifically as possible). If it is the muscle that is contracted then documentation should include whether this was an acquired or congenital condition, does the muscle contracture include a joint and, if so, which joint. Other descriptive information would be helpful, i.e. hysterical, ischemic, posttraumatic, or psychogenic in nature. Joint stiffness documentation can code out to a contracture or postoperative/postprocedural ankylosis (due to fusion of the bones). The more descriptive the documentation is the better we can code to specifics. Hope this was helpful.