Eli's Rehab Report

Follow expert tips to ensure rotator-cuff injury claims get a clean bill of health

A summer full of baseball games and swim meets means coding for a lot of rotator-cuff injuries. When a surgeon refers a patient with this condition to your rehab practice, don't be caught guesstimating - instead learn your ICD-9 Codes and CPT Codes options before one of these charts hits your desk.

Avoid Relying on Referring Provider's ICD-9 Selection

The first thing to remember when coding rotator-cuff injuries (also known as "swimmer's shoulder" or "pitcher's shoulder") is that your therapist sees patients for rotator-cuff therapy after the patients have undergone surgery for this condition. As a result, you probably won't be able to use the referring physician's diagnosis (726.10, Rotator cuff syndrome; 727.61, Nontraumatic complete rupture of rotator cuff; or 840.4, Sprain/strain rotator cuff) because after surgery, these diagnoses no longer accurately represent the patients' current condition. Payers consider rotator-cuff injuries "cured" after surgery, says Carl Byron, ATC-L, EMT-I, CPC, principal of Health Care Consulting Services Inc. in Hickory, N.C.

When diagnosis coding for these patients, "you should focus on the problem(s) the therapist is treating, such as scarring or adhesions (726.0, Adhesive capsulitis of shoulder), pain with joint movement (719.41, Pain in joint, shoulder), or decreased range of motion (719.51, Stiffness of joint, not elsewhere classified, shoulder region)," Byron says. These should serve as your primary diagnosis codes.

For a secondary diagnosis, you may try to use a V code for status post surgery (V45.89, Other postprocedural status; other). Two codes may be necessary to tell the insurer the complete story, says  Beth P. Janeway, CPC, CCS-P, CCP, president of Carolina Healthcare Consultants.

You may also use an E code to describe to the payer how the occurrence happened (such as E849.4, Place for recreation and sport).

Ask, What Is the Focus of the Treatment?

When the patient first presents to your office, your therapist will evaluate him. For this service you should report either 97001 (Physical therapy evaluation) or 97003 (Occupational therapy evaluation) depending on the documentation. During this initial visit, your therapist will focus on the mechanism of the injury, the history of the injury, the length of time the patient has played the sport, and how exactly the injury occurred (such as, overuse, poor form, a one-time acute event). Then your therapist will evaluate the surgery's effects and look for present pain, range of motion, scarring, as well as the extent/severity of the injury.

After an injury and again after surgery, the rotator cuff loses its ability to fire properly in the best neuromuscular sequence. The therapist's work centers on regaining normal strength as well as stabilization, internal and external rotation, Byron says.

After the evaluation (97001 or 97003), the therapist draws up a plan of care and sets goals. For the phases I-IV of rehabilitation (which may last up to six months), the therapist may perform manual stretching, active-assisted exercises, and other specific exercises aimed at rotator-cuff sections independently. Because these exercises are essentially similar, you've got many related therapy code options to choose from.

Key: Ask, "What is the focus of the treatment accomplished by this exercise?" Byron says.

For example, if your therapist performs dumbbell exercises to gain strength and grow the muscles, you would report 97110 (Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility).

However, if your therapist performs these same dumbbell exercises and documents his rationale as proprioception and neuromuscular education, you would report 97112 (... neuromuscular re-education of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities).

Other options: Your most likely choices will also include 97124 (... massage, including effleurage, petrissage and/or tapotement [stroking, compression, percussion]) for massage or 97140 (Manual therapy techniques [e.g., mobilization/manipulation, manual lymphatic drainage, manual traction], one or more regions, each 15 minutes) for manual mobilizations, if needed. If the therapist performs a specific mechanical test, such as Biodex or Kincom, you'd report 97750 (Physical performance test or measurement [e.g., musculoskeletal, functional capacity], with written report, each 15 minutes).

Each of these codes occurs in a 15-minute increment. This means that you'll report units according to the 8-minute rule. For example, if your therapist documents performing 20 minutes of 97110, you should report only one unit. When you consult your 8-minute rule chart, you'll see that one unit equals 8 minutes to less than 23 minutes. (If you would like a free PDF chart of the 8- minute rule, e-mail me at suzannel@eliresearch.com.)

Heads up: You may also report 97530 (Therapeutic activities, direct [one-on-one] patient contact by the provider [use of dynamic activities to improve functional performance], each 15 minutes) for rotator-cuff repair rehab patients - a more functional component code than 97110, Byron says.

Another option could be 97150 (Therapeutic procedure[s], group [2 or more individuals]). Remember, Medicare expects no more than one group therapy code per day. More than that and you've got to provide supporting documentation. If you're a facility/institutional therapy setting, however, you can apply the group therapy more than once. To avoid confusion over reporting this group code alongside other one-on-one therapy codes, you may want to ask your payer for pre-approval.

Don't Discriminate Based on Age

Remember that when coding rehabilitation services, your coding stays the same regardless of the patient's age. Although your therapist must constantly be aware of pediatric requirements and restrictions, the rotator-cuff tear is the same ICD-9 code for patients of any age. Your CPT choices will also remain the same, but bear in mind that you may need to represent extra time the therapist may need to spend with children.