essentially you do have two problems here.. first you have a referral from the provider for rehab, which is coded with the V57.1 first listed for rehab claims. As far as your therapist diagnosing pain and then treating it without a physician referral for it depends on the payer. But it is best to separate your rehab encounters from your pain control encounters. Pain control/management is coded with the appropriate 338.xx code first listed and then the cause of the pain or location of the pain secondary, look in your coding guidelines for all this information. Then check with the payer as to whether you are required to have a new referral upon the therapist finding a new problem.
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