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  • Andrea Ryan

How to Get Specific with ICD-10 Codes and Get Paid Faster

In the United States, physical therapists use ICD-10 codes to bill for their services.

Despite the fact that every practicing therapist is familiar with the process of searching for and selecting these codes, many have never learned about their structure, purpose, and how to select a code that maximizes their chances of having their insurance cover their services. Keep reading for a primer on physical therapy ICD-10 codes and how to avoid common coding mistakes.

ICD-10 codes for physical therapy: what are they?

Physical therapists use ICD-10 codes every day in their practice to diagnose, describe symptoms, and code procedures. HIPAA-covered healthcare providers, including physical therapists, transitioned from ICD-9 to ICD-10 in 2015. Among the ICD-10 codes for physical therapy, there are two: ICD-10 CM and ICD-10 PCS. This article will not discuss the PCS code set, which is only used for inpatient procedures. Clinical Modification codes are used in clinical settings in the U.S. and will be discussed in more detail below.

ICD codes are designed to make mortality statistics collection, processing, classification, and presentation more comparable internationally, according to the Centers for Medicare and Medicaid Services. These documents provide insurance companies with information about a medical diagnosis that identifies the cost of the care you are providing, so they can determine whether the care is medically necessary and therefore reimbursable. When seeking reimbursement from an insurer, HIPAA-covered entities must submit these physical therapy ICD-10 codes. The primary code will be the one that describes the primary condition and symptoms associated with it. However, it is possible to select multiple codes describing the primary condition and symptoms associated with it.

The ICD-10 codes for physical therapy are all alphanumeric. There is a decimal point after the third character and they always begin with a letter. More characters mean more specificity. The structure of each code is as follows:

  • Characters 1-3 indicate the category of the diagnosis

  • Characters 4-6 indicate etiology, anatomic site, severity or other clinical detail

  • Character 7 is an extension value.or example:

  • A: Initial encounter (anything related to care of the initial injury)

  • D: Subsequent encounter (anything related to the phase of routine care of the injury while the patient recovers–this usually refers to rehabilitation)

  • S: Sequela (other conditions that may result from the presence of the primary condition)

It's important to note that fracture care has several additional extensions (such as P, G, and K, which indicate malunions, delayed healings, and nonunions for a subsequent encounter).

At least on the first visit, select the ICD code with the most applicable characters. It is more likely that reimbursement will be granted if you are more specific with your physical therapy ICD-10 code, but you must always support it with the patient's medical record and personal knowledge of the patient's condition.

Mistakes to avoid when coding in ICD-10 for physical therapy

Electronic health records like the one that comes native to PatientStudio make finding a physical therapy ICD-10 code as simple as typing words into a search box. Immediately, the condition for which you are searching will be displayed in a list of codes. The use of charting software makes it easy to find relevant ICD-10 codes for physical therapy. Understanding which code to select is not as easy because the most obvious code is not necessarily the one that will guarantee reimbursement by the insurance provider.

There are a number of common physical therapy ICD-10 coding errors that can result in the insurance company denying your claim, even if your treatments are medically necessary and should be covered. Here are some coding errors to look out for.

Codes that are not billable or specific

Physical therapy ICD-10 codes are highly specific, so many of the most obvious and simplest codes are not billable as primary codes. On the free ICD10 Data website, you can find a list of over 20,000 nonspecific codes. You can determine whether a code is billable as a primary code by looking for a green or red arrow (as well as its description).

Diagnoses at multiple sites

It is possible that you are treating symptoms or conditions that are affecting multiple sites in the body at the same time. In the case of gout in multiple joints or osteoarthritis in several joints, for example. To indicate that osteoarthritis exists in more than one location, we might choose the code M19: osteoarthritis. Reimbursement should not be made with this code since it is considered a nonspecific code.

Consider using ICD-10 codes that include multiple sites when possible instead. An example would be M43.19: Spondylolisthesis, multiple sites in the spine. It is recommended to include a physical therapy ICD-10 code for each body site involved if a "multiple sites" option is not available for that diagnosis.

Physical therapy ICD-10 codes can help increase the specificity of the primary diagnosis during the initial evaluation. Suppose you are treating a soccer player who sprained his medial collateral ligament on the field and came straight to you directly through direct access. In this case, the primary code would be S83.411A (Sprain of medial collateral ligament of knee, initial encounter) with W50.0XXA as the external cause and Y92.328 as the place of occurrence. Follow-up visits typically do not include the external cause and place of occurrence codes.

We now have a better understanding of the purpose and structure of physical therapy ICD-10 codes, as well as some common examples and how we can use these concepts in real-life situations.

Low back pain with sciatic nerve pain:

Low back pain resulting from car accident 2 weeks ago:

Follow-up codes that could be reported:

  • M54.41: Lumbago with sciatica, right side

  • R26.89: Other abnormalities of gait and mobility

  • R53.1: Weakness of right leg

Knowing and understanding the best physical therapy ICD-10 code is crucial to getting paid. The PatientStudio EHR can provide you with the best codes at your fingertips so that your team can focus on other tasks. With PatientStudio, you can schedule, bill, and document your medical appointments in one easy-to-use platform.

Curious? Sign up for a product demo to see how PatientStudio can help you code your treatments most accurately and get you the maximum reimbursement dollars.