ICD-10 Coding Example: Physical Therapy

The era of the International Classification of Diseases, tenth revision (ICD-10) has been with us for quite some time now, and while most practices and healthcare groups have gotten the coding system fairly well in hand by now, there are always questions regarding accuracy and specificity with the complex coding structure. This is especially apparent when the topic of ICD-10 in physical therapy.

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The biggest distinction between ICD-9 and ICD-10 is that ICD-9 was characterized by the more applicable codes that can be applied to a patient’s case, the better. Well, in ICD-10 less is more, so you want to try and assign only the codes that most accurately and specifically characterize the patient’s dysfunctions and issues. To help you or your fellow rehab therapists, here are two quick examples—with some related codes—for using ICD-10 in physical therapy.

An ICD-10 Diagnosis Code Example for ACL Sprain

The patient is a 16-year-old male high school athlete. During a soccer game last week, his knee came into contact with another player’s leg. He comes directly to physical therapy—without a physician referral—and presents with pain, edema, and instability in his right knee. Upon coming into your office, he explains that he’s using crutches for ambulation and is experiencing pain while walking. You’re certain he’s sprained his ACL, but how do you code this condition accurately? Here’s how:

The ICD-10 Codes

• S83.511A, Sprain of anterior cruciate ligament of the right knee, initial encounter. 

• Remember, this is a direct access patient, so you’d use “A” as the seventh character.

• W51.XXXA, Accidental striking against or bumped into by another person, initial encounter.

• This is an external cause code that further describes the factors leading up to the injury.

• Y92.322, Soccer field as the place of occurrence of the external cause. 
• Y93.66, Activity, soccer

Additional Codes for this Case

Furthermore, you’d want to code the reason the patient is seeking your treatment:

• R26.2, Difficulty in walking, not elsewhere classified, or R26.89, Other abnormalities of gait and mobility 
• M25.561, Pain in the right knee
• M25.361, Other instability, right knee
• M25.461, Effusion, right knee

The Description Synonyms

You’ll notice you could code either R26.2 (difficulty walking) or R26.89 (other abnormalities of gait and mobility). That’s because, depending on your evaluation, you might discover the reason behind the disordered movement is best described by one code more than the other. Each code has its own synonyms that can help you make your selection. For example:

Difficulty walking

The description synonyms for R26.2 are:

1. Difficulty walking
2. Walking disability

Other abnormalities of gait and mobility

The description synonyms for R26.89 are:

1. Cautious gait
2. Gait disorder due to weakness
3. Gait disorder, painful gait
4. Gait disorder, weakness
5. Gait disorder, postural instability
6. Gait disorder, multifactorial
7. Toe-walking and toe-walking gait
8. Limping/limping child

The ICD-10 Reasoning

Those eight individual codes that would be applicable for this case where a patient comes to treatment from a direct access perspective. That is not to say that all eight codes should or need to be applied, but they are all applicable. When applying an ICD-10 code for physical therapy, remember that they need to be accurate and specific to show medical necessity, and—in many cases—less is more. With that in mind, let’s move on to a new example that is more commonly seen as a referral after orthopedic surgery.

An ICD-10 Diagnosis Code Example for a Total Knee Replacement

This example will likely prove a bit more straightforward than the previous, as this patient comes to your clinic with a referral from their surgeon after an outpatient surgery for a right total knee arthroplasty/replacement (TKA/R). The patient has a chronic history of right knee osteoarthritis and underwent the TKR to reduce pain and improve participation in functional tasks and quality of life. Presently, the patient is using a two-wheeled walker due to right knee weakness and pain and has limited mobility due to their acuity and post-op status. You initiate care with the initial evaluation and will likely need to use a few codes pertaining to the patient’s referral and need for skilled PT.

The ICD-10 Codes

This ICD-10 example will require the use of Z codes as the patient has received surgery and ongoing care for their post-treatment healing or recovery phase is necessary. For more information on Z codes, check out this post. In the meantime, let’s jump into the nitty gritty:

• Z47.1, Aftercare following surgery for joint replacement
• Z96.651, Status (post), organ replacement, by artificial or mechanical device or prosthesis of, joint, knee-see presence of knee joint implant

Additional Codes for this Case

The use of only Z codes is not always a good idea. By using additional codes that describe what the patient is dealing with now, post-surgery, you can better detail what your PT interventions are seeking to address. Some applicable ICD-10 codes could include:

• R26.89 Other abnormalities of gait and mobility 
• M25.561, Pain in the right knee
• M25.361, Other instability, right knee
• M25.461, Effusion, right knee

The ICD-10 Reasoning

Hopefully, this example is a bit more straightforward and gives a clear picture of what your ICD-10 codes for physical therapy should look like for a patient with a TKR. Remember though— the additional codes are suggested to define what you specifically want to address in your care, so if the patient does not suffer from knee instability (other a different example), and your documentation does not support it, do not include those specific ICD codes.

‍

There you have it: two examples of how—and when—to use ICD-10 in physical therapy outpatient practices. Unfortunately, choosing the right code for ICD-10 can still feel a bit perplexing and intimidating—especially when they can determine your revenue and possible visit authorizations. So, by using an intelligent ICD-10 selector like the one used in WebPT’s EMR, you can take the stress out of selecting the right code and simplify your clinical workflows.The era of the International Classification of Diseases, tenth revision (ICD-10) has been with us for quite some time now, and while most practices and healthcare groups have gotten the coding system fairly well in hand by now, there are always questions regarding accuracy and specificity with the complex coding structure. This is especially apparent when the topic of ICD-10 in physical therapy.

The biggest distinction between ICD-9 and ICD-10 is that ICD-9 was characterized by the more applicable codes that can be applied to a patient’s case, the better. Well, in ICD-10 less is more, so you want to try and assign only the codes that most accurately and specifically characterize the patient’s dysfunctions and issues. To help you or your fellow rehab therapists, here are two quick examples—with some related codes—for using ICD-10 in physical therapy.

An ICD-10 Diagnosis Code Example for ACL Sprain

The patient is a 16-year-old male high school athlete. During a soccer game last week, his knee came into contact with another player’s leg. He comes directly to physical therapy—without a physician referral—and presents with pain, edema, and instability in his right knee. Upon coming into your office, he explains that he’s using crutches for ambulation and is experiencing pain while walking. You’re certain he’s sprained his ACL, but how do you code this condition accurately? Here’s how:

The ICD-10 Codes

• S83.511A, Sprain of anterior cruciate ligament of the right knee, initial encounter. 

• Remember, this is a direct access patient, so you’d use “A” as the seventh character.

• W51.XXXA, Accidental striking against or bumped into by another person, initial encounter.

• This is an external cause code that further describes the factors leading up to the injury.

• Y92.322, Soccer field as the place of occurrence of the external cause. 
• Y93.66, Activity, soccer

Additional Codes for this Case

Furthermore, you’d want to code the reason the patient is seeking your treatment:

• R26.2, Difficulty in walking, not elsewhere classified, or R26.89, Other abnormalities of gait and mobility 
• M25.561, Pain in the right knee
• M25.361, Other instability, right knee
• M25.461, Effusion, right knee

The Description Synonyms

You’ll notice you could code either R26.2 (difficulty walking) or R26.89 (other abnormalities of gait and mobility). That’s because, depending on your evaluation, you might discover the reason behind the disordered movement is best described by one code more than the other. Each code has its own synonyms that can help you make your selection. For example:

Difficulty walking

The description synonyms for R26.2 are:

1. Difficulty walking
2. Walking disability

Other abnormalities of gait and mobility

The description synonyms for R26.89 are:

1. Cautious gait
2. Gait disorder due to weakness
3. Gait disorder, painful gait
4. Gait disorder, weakness
5. Gait disorder, postural instability
6. Gait disorder, multifactorial
7. Toe-walking and toe-walking gait
8. Limping/limping child

The ICD-10 Reasoning

Those eight individual codes that would be applicable for this case where a patient comes to treatment from a direct access perspective. That is not to say that all eight codes should or need to be applied, but they are all applicable. When applying an ICD-10 code for physical therapy, remember that they need to be accurate and specific to show medical necessity, and—in many cases—less is more. With that in mind, let’s move on to a new example that is more commonly seen as a referral after orthopedic surgery.

An ICD-10 Diagnosis Code Example for a Total Knee Replacement

This example will likely prove a bit more straightforward than the previous, as this patient comes to your clinic with a referral from their surgeon after an outpatient surgery for a right total knee arthroplasty/replacement (TKA/R). The patient has a chronic history of right knee osteoarthritis and underwent the TKR to reduce pain and improve participation in functional tasks and quality of life. Presently, the patient is using a two-wheeled walker due to right knee weakness and pain and has limited mobility due to their acuity and post-op status. You initiate care with the initial evaluation and will likely need to use a few codes pertaining to the patient’s referral and need for skilled PT.

The ICD-10 Codes

This ICD-10 example will require the use of Z codes as the patient has received surgery and ongoing care for their post-treatment healing or recovery phase is necessary. For more information on Z codes, check out this post. In the meantime, let’s jump into the nitty gritty:

• Z47.1, Aftercare following surgery for joint replacement
• Z96.651, Status (post), organ replacement, by artificial or mechanical device or prosthesis of, joint, knee-see presence of knee joint implant

Additional Codes for this Case

The use of only Z codes is not always a good idea. By using additional codes that describe what the patient is dealing with now, post-surgery, you can better detail what your PT interventions are seeking to address. Some applicable ICD-10 codes could include:

• R26.89 Other abnormalities of gait and mobility 
• M25.561, Pain in the right knee
• M25.361, Other instability, right knee
• M25.461, Effusion, right knee

The ICD-10 Reasoning

Hopefully, this example is a bit more straightforward and gives a clear picture of what your ICD-10 codes for physical therapy should look like for a patient with a TKR. Remember though— the additional codes are suggested to define what you specifically want to address in your care, so if the patient does not suffer from knee instability (other a different example), and your documentation does not support it, do not include those specific ICD codes.

‍

There you have it: two examples of how—and when—to use ICD-10 in physical therapy outpatient practices. Unfortunately, choosing the right code for ICD-10 can still feel a bit perplexing and intimidating—especially when they can determine your revenue and possible visit authorizations. So, by using an intelligent ICD-10 selector like the one used in WebPT’s EMR, you can take the stress out of selecting the right code and simplify your clinical workflows.