Eli's Rehab Report

Hint: Pay attention to whether procedures are timed

Therapy coders may think they can code any therapy note, but some documentation may throw you for a loop.

Check out the following PT progress note and decide how you would code it.

Note: The documentation is in "SOAP" note format, first listing subjective information ("S"), then the objective during therapy and what techniques the therapist used with the patient ("O"), followed by the therapist's assessment ("A"), and the plan ("P").

"This is a good way to document your notes to make sure you don't miss any items," says Jay Neal, an independent coding consultant in Atlanta.
 
Scrutinize the Progress Note

S: Patient states compliance with home exercise program. States increased use of right upper extremity with shoulder level and below activities of daily living (ADL) tasks.

O: Moist hot pack to right shoulder joint capsule for 20 minutes followed by 15 minutes grade-3 anterior, posterior and inferior joint mobilizations to the right shoulder. 20 minutes manual stretching using contract-relax method to increase shoulder flexion, abduction, and external and internal rotation AROM.

Shoulder flexion, abduction, external rotation and internal rotation strengthening exercises in the standing position using red theraband, all three sets times 10 repetitions (15 minutes total). Provided patient with red theraband to use when performing exercises at home. Shoulder AROM after treatment was as follows: flexion 125 degrees, abduction 118 degrees, external rotation 56 degrees, and internal rotation 54 degrees.

A: Shoulder AROM increased 10 degrees for flexion and abduction and 8 degrees for external and internal rotation after joint mobilizations and manual stretching. Patient compliant with home exercise program. Improved ability and tolerance with ADL tasks at shoulder level and below using right upper extremity.

P: Continue with aggressive manual stretching and add grade-4 joint mobilizations next treatment.

Answer to 'Can You Code This Therapy Note?'

Did you code our sample PT note correctly? Check out our expert advice to determine whether you made the grade:

First, you should report one unit of CPT 97010 (Application of a modality to one or more areas; hot or cold packs) for the hot-pack application. 

Remember that 97010 is not a timed code, so even if the therapist had applied hot packs intermittently totaling 35 minutes, you would still only code one unit of 97010.

Second, you should submit one unit of 97140 (Manual therapy techniques [e.g., mobilization/manipulation, manual lymphatic drainage, manual traction], one or more regions, each 15 minutes) for the 15 minutes of manual therapy.

Rationale: "I have seen coders before who see the documentation of joint mobilization and immediately go for the therapeutic exercise code (97110), but that is incorrect," says Amy Nasser, a physical therapist in Kansas City. "Joint mobilization is a series of small passive movements, usually applied as a series of gentle stretches in a smooth, rhythmic fashion to the affected joint. The mobilization relieves restricted movement and stretches stiff joints to restore range."

Therefore, she says, 97140 is the accurate code.

You should report two units of 97110 (Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility) for the 20 minutes of manual stretching and 15 minutes of strengthening exercises using the theraband.

Tip: You can report A9300 (Exercise equipment) to collect reimbursement for the cost of the theraband that the therapist provided to the patient.

Here's your chance: Do you have a challenging note that you are unsure how to code? We would love to see it, and perhaps feature it as an upcoming progress-note quiz. Just send it to our editor, Suzanne Leder, CPC, at suzannel@eliresearch.com.