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Eli's Rehab Report

Reader Question:

Matching ICD-9 Codes

Published on Tue Jan 01, 2002

Question: Sometimes our therapist receives orders from the physiatrist with diagnoses not listed in the CPT Codes local medical review policy (LMRP). However, a symptom of that condition is listed as acceptable on the LMRP. Should we bill using the symptom being treated and billed on the plan of care, or must we return the physician's order and ask him to change it from the condition to the symptom so the diagnosis is consistent throughout the medical record?

Alabama Subscriber
 
 
Answer: The short answer to your question is that if you are treating the specific symptom that also happens to be listed as acceptable on the LMRP, by all means code your claim using it.
 
Your concern is that you are coding not according to the condition you are treating, but according to what the LMRP accepts. This is not correct coding.
 
The physician's plan of care should already include the patient's symptoms. For example, if the patient had a stroke, the plan of care might request that the therapist work on gait training to help the patient strengthen the muscle weakness in her left side. If your LMRP does not list stroke (436) as an acceptable ICD-9 for gait training (97116), but does list muscle weakness (728.9), you can and should code the claim using the muscle weakness code because that is the condition that you as a therapist are treating.
 
However, suppose the patient had a stroke and is experiencing pain in her hand. The physiatrist writes in the plan of care that the patient should work on grasping exercises for her hand, and also on gait training, but does not explain the gait training. You should not assume that since muscle weakness is listed on the gait training LMRP that this is the reason the physiatrist has requested it for the patient.
 
In this case, you should go over the plan of care in detail with the physiatrist to pinpoint the reasons for the gait training. Hand weakness would not warrant gait training, so you need to work with the physician to create a more detailed plan of care so you can treat the patient most effectively. In turn, you will be able to better target an ICD-9 code for your claim.
 
If, after discussing the patient's condition with the physiatrist, you determine that the patient does not have a problem listed as an applicable diagnosis, but the doctor and the patient still feel it's worthy to perform the gait training, tell the patient that the service may not be covered. Ask the patient to sign an advance beneficiary notice so the practice can collect payment from the patient if the service is denied by Medicare.
 
Do not "massage" the plan of care in any way to include codes for diagnoses the patient does not have. An auditor would notice this inconsistency, and both you and the physiatrist would have to answer to whomever the auditor is representing.

Answers to Reader Questions and You Be the Coder were provided by Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, consultant and CPC trainer for A+ Medical Management and Education, a national coding and reimbursement school and consulting firm in Absecon, N.J.; and James Cronin, office manager at Cities PM&R in St. Paul, Minn.

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