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Coding for Physical Therapy.

  1. #1
    Red face Coding for Physical Therapy.
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    Can anyone share some light on how they procsses their tickets in a physical therapy's office as far as how the coder codes each fee slip. With our new evaluations we code from the dictation and then carry all of them diagnosis over to each subsequent vist for that same plan of care. Now our system allows the diagnosis to print again on each ticket until a we change it with a new evaluation. Our new system will not allow the diagnosis to print on our fee slips any more. So I will need to code each subsequant visit. The problem is the Therapist does not always mention all the diagnosis in his daily notes for the subsequent visits, so there really isn't any daily note for me to code from. What are other offices doing to code there fee slips? Thanks for any input.

  2. #2
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    I work in an outpatient hospital therapy department and we require treatment diagnosis on all of our therapists notes. For auditing and documentation integrity purposes it is really important that every note contain the treatment diagnosis (what the physical therapist is working on i.e. difficulty walking, lack of coordination, disorders of sacrum, etc.) and the medical diagnosis from the physician (e.g. degenerative disc disorder thoracosacral region, OA, etc.) therapists will always treat the effects of the medical condition, not the condition itself.

  3. #3
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    If you look on page 12 of the coding guidelines item number 15 it states the first listed dx code for rehab encounters is required to be a V57.x code and the secondary code is the reason for the rehab which would be the late effects of an injury or as stated above the effects of the underlying medical condition.

    Debra A. Mitchell, MSPH, CPC-H

  4. Default
    Do you have any advice for coding physical therapy post orthopedic surgery? We have been using V57.1 followed by V54.89 for other orthopedic aftercare. I'm not sure if we should be coding the acute injury as well based on the guideline under aftercare "Certain aftercare V code categories need a secondary diagnosis code to describe the resolving condition or sequelae..."

    Ex: A patient is status post rotator cuff repair for an acute rotator cuff tear. Would you code 840.4?

  5. #5
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    Columbia, MO
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    If they are post rotator cuff repair then they no loger have an acute tear so no you no longer use the 840.4. You will use the V57.1 followed by the condition that needs rehab (possibly stiffness) followed by the 905-907 code for the late effect of the injury code.

    Debra A. Mitchell, MSPH, CPC-H

  6. Default
    Thanks Deb! Do you know if I can code based on the physical therapist's documentation of the condition (stiffness)?

  7. #7
    Location
    Columbia, MO
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    yes, they are not rendering a dx they are following the physicians directive for the condition that needs rehab. The condition is a symptom and not a definitive dx such as arthritis.

    Debra A. Mitchell, MSPH, CPC-H

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