2. With ICD-10 there are guidelines for specific diagnoses
by chapter that, unless otherwise indicated, apply to
both outpatient and inpatient settings.
ICD-10 Guidelines
3. Codes that describe signs and symptoms are acceptable for
reporting purposes when a related definitive diagnosis has not
been established.
Coding signs and symptoms should not be reported with a
confirmed diagnosis if the symptom is integral to the diagnosis.
Example: A patient is experiencing pain in their shoulder and the
diagnosis is bicipital tendonitis of the left shoulder , the shoulder
pain is an integral part of the bicipital tendonitis and does not need
to be coded.
Signs and Symptoms
4. If you know what is causing the pain, you should code for
the underlying condition instead—although in some cases,
it might be appropriate to submit both codes.
The ICD-10-CM guidelines state that if the cause of the pain
is known, you should assign a code for the underlying
diagnosis, not the pain code. However, if the purpose of the
encounter is to manage the pain rather than the underlying
condition, then you should assign a pain code and sequence
it first
Signs and Symptoms Cont.
5. Patient comes in complaining of left hip pain. The patient also has
a history of left sided cerebrovascular accident, which is causing
increased weakness, along with the a pain, due to the accidents
affect on the left non-dominant side.
M25.551- Pain in right hip
R169.354- Hemiplegia and hemiparesis following cerebral
infarction affecting the left non-dominant side
Example!
6. Whenever possible, you should account for the cause of
the injury (e.g., sports, motor vehicle accident, or slip and
fall) and/or the activities leading up to the injury by
submitting applicable external cause codes along with the
injury code
f you know where the injury occurred (e.g., gym, athletic
field, or swimming pool), you should code for it using an
appropriate place of occurrence.
Both etiology and place of occurrence codes are located in
Chapter 20
Etiology and Place of Occurrence
7. Description of injury: Left knee strain that occurred on a
private recreational playground when a child jumped off of a
trampoline and landed incorrectly.
Injury code: S86.812A, Strain of other muscle(s) and
tendon(s) at lower leg level, left leg, initial encounter
External cause code: W09.8XXA, Fall on or from other
playground equipment, initial encounter
Place of occurrence code: Y92.838, Other recreation area as
the place of occurrence of the external cause
Activity code: Y93.44, Activities involving rhythmic
movement, trampoline jumping
Example Time!
8. Acute and Chronic- Many musculoskeletal conditions are a result
of previous injury or trauma to a site, or are recurrent conditions.
When and patient I being treated for the acute injury that if from
a chronic condition, always code the acute injury first followed by
the chronic condition.
EXAMPLE!
A patient is coming in direct access, due to an injury on his right
knee that is a chronic injury.
S83.281A- other tear of lateral meniscus, current injury, right
knee, initial encounter
M23.361- other meniscus derangements, other lateral meniscus,
right knee
Just a few more rules!
9. Selections of a secondary diagnosis- in most cases more
than one diagnosis code is necessary to fully explain the
healthcare encounter. Although a patient has an encounter
for a principal/first-listed diagnosis the additional conditions
or reasons for the encounter also need to be coded. These
codes are referred to as secondary, additional, or “other
diagnosis”.
“Other diagnoses” is an additional code that affects patient
care in terms of requiring clinical evaluation or therapeutic
treatment.
10. Previous Conditions- Some physicians include in the
diagnostic statement resolved conditions or
diagnoses and status-post procedures from previous
visits that have no bearing on the current treatment.
Such conditions are not to be reported and are coded
only is required by the hospital or physician office
policy.
Last rule…I promise!
11. Not only more codes, More
information needed….
How we can work together to gather as much
information as possible
12. Currently for ICD-9 we are allowed to bill with an unspecified diagnosis,
simply because ICD-9 does not have any further detail to choose from.
With ICD-10 comes the need for more information, as described. By using
our current intake questions we can focus on being more detailed to help
gather the information that is needed to choose the appropriate codes. By
taking this step it can help take care of this information before the patient
comes to see the Therapist, leaving the Therapist to confirm the information
during the initial evaluation insuring it is documented in the patients chart.
How to Collect Necessary
Information
13. By using our current procedures upon intake, we can work
together to gather all the information that is needed,
leaving the Therapist’s to confirm during the initial
evaluation
Sample Intake for Direct Access
14. A patient with direct access has called complaining of an ankle
sprain and would like to schedule:
While speaking with the patient, the front office staff can gather as much
specific information that is possible by using our current intake sheet, just being
more detailed.
“Have you been treated for this ankle sprain before calling our clinic?”
Help determine whether this will be: A- Initial, D- Subsequent, or S- Sequela
“Which ankle did you sprain?”
Helps determine the 5th character, anatomic site; and possibly 6th character,
laterality
“Where did you sprain your ankle and how?”
Helps determine the external cause of morbidity code, Place of Occurrence code,
activity code that all follow the diagnosis code
15. The patient lets you know that he has not seen a doctor for his right
ankle sprain. He also detailed how he fell outside when he was
walking on his driveway that was covered in snow and ice.
With the collected information we can now determine the proper
codes to be:
S93.401A: Sprain of unspecified ligament or right ankle, initial encounter
W00.0XXA: Fall on same level due to ice or snow, initial encounter
Y92.194: Other specified residential institution as place of occurrence, driveway
Y93.01: Activity, walking, marching, and hiking
Sample Intake for Direct Access
Result
16. 1CD-10 General Code Set Training book through AAPC
https://www.webpt.com/blog/post/pt-primer-coding-
pain-and-injuries-icd-10
Sources
