PT Coding Question

dballard2004

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I have a question about ICD-9-CM coding for PT encounters that I would like opinions on, please....

Am I correct that per the ICD-9-CM guidelines, if the patient is presenting for PT and this is the sole purpose of the encounter, you need to report code V57.1 as primary?

I am getting some pushback on this because one of our PTs feels this guidance only applies to the inpatient setting (we are a physician's office) and also we have never billed this code before as we have always just billed the reason for the therapy and we have not been denied from our payers because we have not reported the V57.1 code. Aren't payers required to follow the ICD-9-CM guidelines? I know they have leaway with the CPT rules, but I thought they were required to follow the ICD-9-CM rules due to HIPAA?

Thoughts?
 
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lwhitmire

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Lia Whitmire, RHIA, CPC

I saw this question and I just had to reply. I work in a rehabilitation facility where we treat Inpatients as well as Outpatients for all types of therapies. You would use the V code as the first listed code and then the patients diagnoses. We use the V code as the first listed code and have never had any billing issues. If you do not use the V codes how do they know they are receiving therapy? See listing for the therapy v codes below.

V57.3 – speech
V57.1 PT
V57.21 OT
V57.89 Multiple (more than one therapy)

This should really help you and make it simple. :)

Lia Whitmire, RHIA, CPC
 

mitchellde

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Per the coding guidelines you are correct it is on page 12 number 15 of the guidelines that the V57.x code must be the first listed code. This is not just for inpatient it is for all encounters for rehab. The first page of the guidelines has a paragraph that begins with "these guidelines are a set of rules....." and withing that paragraph it states that adherence to the guidelines is required under HIPAA.
Something I discovered as an auditor was that while many times the claim does get paid without the V57.x... it is paid under the medical benefit and not using the rehab benefits. One clinic I know had a ton of money that had to be refunded due to this. Just because you have never done it this way does not mean you have always been correct!
 

Sueedwards

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Physical Therapy coding

I have a question:

Do you use the physician referral code as the primary diagnosis or do you use the therapist code - meeting medical necessity as the primary diagnosis?

oh... this is outpatient facility.

thanks, Susan
 

mitchellde

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I have never heard of this. I bill for a Physical Therapy group & we use diag related to issue/injury.
Even so just because you have never done it this way does not mean that it is incorrect, and just because you have been paid does not mean you can keep the money.
The Guidelines are required to be adhered to under HIPAA.
 

mitchellde

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I have a question:

Do you use the physician referral code as the primary diagnosis or do you use the therapist code - meeting medical necessity as the primary diagnosis?

oh... this is outpatient facility.

thanks, Susan
You use the V57.x as the first listed and the reason for the rehab as the seconday. Many times the communication from the Dr simple says rehab for hip fracture. And you know this is not correct. You need to query for better information, exactly why do they rehab. Like a gait abnormality or muscle atrophy. And you should use 3rd listed the code for the late effect of fracture from the 905.x category as a third listed. If you get into this habit then ICD-10 Will not be as hard for you.
 

Sueedwards

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Well that is what I thought, and it is in the coding guidelines.

I am not sure what the denial states, that is done in a different department. I was informed that they were being denied.
 
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