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Physical Therapy - Traumatic Rotator

  1. Default Physical Therapy - Traumatic Rotator
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    Our facility has been doing outpatient physical therapy for about 6 months so we still haven't worked all the kinks out. One problem that is frustraiting me is that of Medical Necessity. Medicare doesn't cover diagnoses like Traumatic Rotator Cuff Tear, Lumbar Spondylosis, and Osteoarthritis, but they will cover symptoms like Low back pain, decreased range of motion, and joint pain. The coding guidelines state that we cannot code signs and symptoms when a definite diagnosis has been established, which is making it very hard to code to medical necessity. Here is an example:

    Patient is ordered to have PT for Lumbar Spondylosis. In the initial evaluation the physical therapist states, "patient complains of low back pain . . ." and the doctor signs the bottom of the I.E. Now the I.E. includes a definite dx (that is not medically necessary) yet it also includes a symptom which is medically necessary. However, I feel like this is against coding guidelines. Please tell me if I'm missing something. Thanks.

  2. #2
    Columbia, MO
    If you look in the coding guidelines on page 12 number 15 it tells you to use the V57.x as the first listed dx code and the reson for rehab for the secondary code.You must look to see the reason for the rehab. If the patient had a traumatic rotator cuff tear which was surgically corrected then they are not in rehab for the rotator cuff tear, it may be for decreased rang of motion or weakness in the limb. Gait instability, or passive pain control if it is a chronic problem. If the visit is for pain control then it is not rehab it is pain control which is a 338.xx code.

    Debra A. Mitchell, MSPH, CPC-H

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