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.
Why ICD-10 Codes?
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. Used in 117 nations, ICD-10 codes assist in evaluating diagnoses trends globally. These documents provide insurance companies, care regulators and public health researchers with data about the frequency and costs associated with a medical diagnosis.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.
Do I need to use Physical Therapy ICD-10 Codes?
All healthcare providers, including physical therapists, are required to use ICD-10 codes to report patient diagnoses. Any provider who must comply with the Health Insurance Portability and Accountability Act (HIPAA) must use ICD-10 codes. This remains true for cash-based providers whose patients receive the reimbursement directly from their insurance providers via superbills. Physical Therapists use ICD-10 codes to document detailed descriptions of the diseases, health issues, and complications affecting their patients. ICD-10 codes and the appropriate CPT codes for treatment enable patient billing and insurance reimbursement. To facilitate quick reimbursement, document medical necessity by providing the appropriate physical therapy ICD-10 codes for each patient case that supports the patient’s treatment plan
Structure of Physical Therapy ICD-10 Codes
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. Physical therapy ICD-10 codes can have anywhere from three to seven characters. More characters mean more specificity. The structure of each code is as follows:
Category
Characters 1-3 indicate the category of the diagnosis. In the example above, the letter “S” designates that the diagnosis relates to “Injuries, poisoning and certain other consequences of external causes related to single body regions.” “S,” used with “8” and “6,” indicates that the diagnosis is in the subclass “Injury of muscle, fascia and tendon at lower leg.” A three-character code can be a billable code. However in this case more specificity is required.
Etiology
Characters 4-6 indicate etiology (cause), anatomic site, severity or other clinical detail. In the example above the numbers “0,” “1,” and “1” indicate a diagnosis of “Strain of the right Achilles tendon.”
Extension - The Seventh Character
Last, but definitely not least; the extension. According to CMS, the extension “provides information about the characteristics of the encounter.” Particularly, how many times the patient has sought diagnosis or treatment for their condition. The extension character must always be in the seventh position. If a physical therapy ICD-10 code has fewer than six characters and requires a seventh character extension, you must fill in all of the empty character spaces with a placeholder “X.” A – Initial encounter. This describes the entire period in which a patient is receiving active treatment for the injury, poisoning, or other consequences of an external cause. The most common use of “A” is when a patient comes directly to their physical therapist for diagnoses without a physician referral. This is a common practice in states with direct access.
D – Subsequent encounter. This describes any encounter after the active phase of treatment, when the patient is receiving routine care for the injury during the period of healing or recovery. This is common when the patient has come to their physical therapist as the result of a physician referral.
S – Sequela. A complication or condition that arises as a direct result of an injury. The classic example of a sequela is a scar resulting from a burn.
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
Documentation and charge assignment that comes native to PatientStudio makes 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
To ensure swift reimbursement physical therapy ICD-10 codes need to be highly specific. Example:
M54 -Dorsalgia: Low back pain…. Nonspecific
M54.41 - Lumbago with sciatica, right side … Billable primary code
.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).
Multiple ICD-10 codes for a single condition
It may be required to record multiple codes for a single condition. Notes in the Tabular List indicate whether you’re required to report more than one code. Look for phrases like “Use additional code” or “Code first.”
With injuries, you often will submit external cause codes that further describe what lead to the injury. These secondary codes further describe the cause of an injury or health condition by capturing how it happened.
Example: A patient strained an Achilles tendon while running on a treadmill at a gym. The physical therapy ICD-10 code for running on a treadmill is Y93.A1; the place of occurrence code for a gym is Y92.39; and the external cause status code in this case would be Y99.8, recreating or sport not for income or while a student.
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
The 25 Most Common Physical Therapy ICD-10 Codes
Code | Descriptor |
M54.50 | Low back pain, unspecified |
M54.2 | Cervicalgia |
M25.511 | Pain in right shoulder |
M25.561 | Pain in right knee |
M25.562 | Pain in left knee |
M25.551 | Pain in right hip |
M62.81 | Muscle weakness (generalized) |
M25.552 | Pain in left hip |
R26.2 | Difficulty in walking, not elsewhere classified |
M25.571 | Pain in right ankle and joints of right foot |
M25.572 | Pain in left ankle and joints of left foot |
R26.89 | Other abnormalities of gait and mobility |
Z47.89 | Encounter for other orthopedic aftercare |
R26.81 | Unsteadiness on feet |
M54.6 | Pain in thoracic spine |
M54.16 | Radiculopathy, lumbar region |
M54.12 | Radiculopathy, cervical region |
M54.41 | Lumbago with sciatica, right side |
M17.11 | Unilateral primary osteoarthritis, right knee |
R42. | Dizziness and giddiness (light-headedness, vertigo NOS) |
R26.9 | Unspecified abnormalities of gait and mobility |
M54.42 | Lumbago, with sciatica, left side |
M17.12 | Unilateral primary osteoarthritis, left knee |
Z47.1 | Aftercare following joint replacement surgery |
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.