Eli's Rehab Report

Plans of care may predict your CPT codes, but don't assume all similar injuries are the same

Many patients may arrive to your sports medicine practice with a primary diagnosis already assigned, but in the case of an ACL tear corrected by surgery, it's up to you to assign another diagnostic code.
 
With winter in full force and ski and snowboard lovers hitting the slopes, it's time to refresh your knowledge of winter sports-related injuries. Reviewing which ICD-9 and CPT codes therapists commonly use before you receive your provider's report can make all the difference.

Familiarize Yourself With Common Dx

You'll likely see a lot of ACL (anterior cruciate ligament)/MCL (medial collateral ligament) sprains, strains, and tears (such as 844.2, Sprains and strains of cruciate ligament of knee), says Melissa Windham, office manager of Huston Orthopaedics Surgery and Sports Medicine in Warner Robins, Ga. Ankle sprains, wrist sprains, game keeper, and shoulder sprains also top the list.
 
You may also assign codes for other common injuries such as "fractures, usually ankle, lower leg, femur, and wrist; severe bruising; torn ligaments (usually knee and thumb); and concussion," says Pauline Franko, PT, MCSP, president of Encompass Consulting & Education LLC in Tamarac, Fla.
 
But don't forget back injuries due to snow shoveling, which can occur over and above sports-related injuries, says Lynn Steffes, PT, president/consultant of Steffes & Associates in New Berlin, Wis.

Assigning Primary Dx May Not Be up to You

If the patient comes to your therapy practice, he may have a primary diagnosis from another source. "Other patients with soft-tissue injuries from internists, family practice, pediatrics, or 'doc in the box' come with a general impression, such as ankle sprain, back pain, knee injury - evaluate and treat," Steffes says.
 
For example: If a patient with an ACL tear (844.2) first seeks the help of an orthopedic surgeon, then he will receive a primary diagnosis code there. "We assign our own codes," Windham says.
 
In the case of a patient who had a sports injury and the doctor surgically repaired it, the therapist must assign another diagnosis code, but the surgeon's diagnosis no longer applies, says Carl Byron, ATC-L, EMT-I, CPC, principal of Health Care Consulting Services Inc. in Hickory, N.C. 
 
To enhance reimbursement and fully tell the story of this injury, don't forget to include E codes. "Getting to know E codes will definitely be beneficial," Byron says.  E codes represent the external cause of injury or accident that is the result of environmental events or circumstances.  For winter sports, you can reflect a fall from skis using E885.3 and a fall from a snowboard using E885.4, but you won't find any others. "We most often use for sports accidents E849.4 (Place for recreation and sport), because there aren't any specific codes," Windham says.
 
Note: CMS doesn't require E codes, Franko says.

PT's Plan of Care Predicts CPT Codes

You may have a big clue as to what CPT codes you should assign with a patient's plan of care, but even if your PT treats all ACL patients similarly, don't assume that you will use the same codes. "CMS has really focused on the 'canning' of patients, and the Office of Inspector General (OIG) looks for details in the plan of care that individualize and account for each patient's unique circumstances," Byron says.
 
To continue the example above, the patient with a torn ACL (844.2) due to a fall from skis (E885.3) undergoes reconstructive surgery and requires time in physical therapy to help the knee and surrounding muscles regain strength and improve mobility. 
 
First, the patient sees the physical therapist for his initial evaluation (97001, Physical therapy evaluation). "The patient should always be evaluated for treatment, regardless of a common diagnosis," Steffes says. "The evaluation addresses alignment, flexibility and strength/conditioning for participation in the sport or activity."
 
Note: You don't have to check minutes for 97001, because this code does not carry a time specification.
 
After this first visit, the physical therapist develops a plan of care for the patient. "The therapist develops the plan of care for these injuries the same as any other condition, focusing on the loss of function and the rehabilitation of the patient," Franko says. "The time factor of starting treatment is dependent on the severity and stage of the injury. Normally, this should be no more than one to two days."
 
Usual treatments for winter sports-related injuries include therex, pain modalities, gait training, and aquatic exercises, Franko adds. "We regularly use 97110 (Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility), 97140 (Manual therapy techniques [e.g., mobilization/manipulation, manual lymphatic drainage, manual traction], one or more regions, each 15 minutes), and 97035 (Application of a modality to one or more areas; ultrasound, each 15 minutes)," Windham says. 
 
Heads-up: These treatment codes include "15 minutes" in their descriptors, which should raise a red flag. This means these codes are time-based, and you'll need to report the correct number of units. Make sure the documentation has the specific quantity of times spent on each modality to support your unit calculation.