Eli's Rehab Report

The onset of summer and warm weather often causes a great many people to head outdoors and take up summer sports. Naturally, exercising offers great health benefits, but injuries can occur, particularly if the athletes havent exercised all winter. Physiatrists need to be aware of the ICD-9 codes to use for these common diagnoses as well as which procedural codes are appropriate. Incorrect coding could result in lost revenue or be a red flag for an audit.

According to Craig Liebenson, DC, a practicing chiropractor in Los Angeles, many sports-related injuries are first treated with non-steroidal anti-inflammatory drugs (NSAIDs, which include over-the-counter medications such as Tylenol and Advil), and rest, ice, compression and elevation, before more aggressive treatments are considered.

During the E/M ( CPT 99201 - 99215 ), he also evaluates the patients exercise regime, looking for some discovery of what led to the injury, whether it was acute trauma or cumulative overload, and whether poor training habits such as a sudden increase in activity or inadequate warmup were part of the onset.

If the patient is a weekend warrior, he advises training for the activity, which may involve a combination of biomechanical advice and conditioning exercises, (97110, 97140, 97150). In spite of good advice being available, PM&R practices see several injuries that are repeated often among their patients who are summer-only athletes.

Lateral and Medial Epicondylitis

According to Liebenson, tennis and baseball enthusiasts often experience lateral and medial epicondylitis (ICD-9 726.32 ; 726.31 ) from straining or overusing their arm muscles, or from beginning to exercise without properly warming up. Known as tennis elbow, lateral epicondylitis is an inflammation of the wrist extensors at their origin (which is the lateral epicondyle of the elbow.)

Lateral epicondylitis can be a stubborn condition to treat, says Arthur Androkites, MD, a PM&R physician in Greensburg, Penn. Its a very common problem that often requires pain relief and reducing inflammation with treatments such as ice (97010, application of a modality to one or more areas; hot or cold) or anti-inflammatory medication (such as Vioxx) and working on muscle strengthening and stretching the forearm extensor muscles (97110, 97140, 97150), which often would be referred to a physical therapist. For tennis elbow, counterforce wraps (97140) take pressure off of the lateral epicondyle area, and ice massage (97124) can be helpful.

Running Injuries

Running causes injuries year-round, but because it is involved in so many other sports, such as baseball, soccer and tennis, more running injuries occur in the summer than the rest of the year. Liebenson says that many runners experience patello-femoral (726.64 ) and achilles tendonitis (726.71) disorders, which also are treated initially with ice or anti-inflammatory medication, and often are referred to a physical therapist or sports-oriented chiropractor for exercises or electrical (97014) or thermal therapies (97024, 97026, 97028).

Rotator Cuff Injuries

Swimmers, volleyball players and tennis enthusiasts often experience rotator cuff disorders (torn rotor cuff, 727.61, rotator cuff tendonitis, 726.0) from overuse or overextension of the shoulder.

Impingement [weakening, or degeneration of the rotator cuff] is a common problem, says Androkites, and, again, the first step with rotator cuff problems is to reduce inflammation with anti-inflammatory medications and ice. Then, the patient should use therapy and exercises to work on stretching and strengthening the rotator cuff. If a patient is not able to reduce the problem, then sometimes treatment may involve corticosteroid [e.g., Depo Medrol (J1020, J1030, J1040)] injections into the bursa (20605, arthrocentesis, aspiration or injection; intermediate joint).

Androkites states that other common injuries, such as back pain, groin pulls and stiff necks, normally dont require any treatment beyond ice and stretching, while more severe conditions, for example, traumatic injuries to the wrist and hand such as are often seen in rollerblading or cycling accidents, generally are referred to orthopedists.

Practices should note that physical therapists evaluations should be billed separately from the physicians E/M codes, using 97001 for a physical therapy evaluation and 97002 for a physical therapy reevaluation.

Medicare and most other carriers will not reimburse for both a physicians E/M and a physical therapy evaluation from the same practice on the same day. Most carriers will, however, pay for an E/M and a physical therapy procedure on the same day (such as 97140). Individual modalities should be billed using their own CPT codes, as outlined in the Physical Medicine/Rehabilitation section of CPT 2000. Its also important to note that Medicare and some private carriers restrict coverage for certain physical medicine codes (such as massage, 97124, and acupuncture, 97780), so check your carriers policies before billing these codes.