ICD-10 Coding Example: Physical Therapy

Have you worked hard throughout the year to train your ICD-10 muscles? Do you feel brainy-buff enough to join the ranks of ICD-10 experts come October 1? If not, you’re not alone. That’s exactly why we’re hosting an ICD-10 bootcamp webinar: To whip you into tip-top-coding shape. I trust that with the help of WebPT founder and COO Heidi Jannenga and coding expert Rick Gawenda, that you, too, can pull up on your coding bar and get to sprinting straight toward a successful ICD-10 transition. Want a sneak peek of what we’ll cover in the webinar? Ask, and you shall receive. Here’s an example:

ACL Sprain

The Patient

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 Codes

The Reason for Outpatient Therapy

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 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 How-To

So, there you have it: An accurate description of an ACL sprain in only eight codes. Easy peasy, right? Want to see how to select ICD-10 codes in WebPT—or how to locate them in the tabular list? Join us for our free ICD-10 bootcamp webinar on August 31. We’ll cover this example—and ones that are even more complex—step-by-step. Don’t worry, you don’t have to give us your fastest mile time; simply register here to reserve your spot.