Eli's Rehab Report

These 2 scenarios challenge what you've learned

You've gotten a taste of coding for winter sports- related injuries, so now put it to the test.
 
Scenario 1: An avid winter sportsman falls from his snowboard at a local mountain resort and severely sprains his ankle. He has ankle pain, swelling, instability, and laxity from his sprain. His primary-care provider diagnosed a grade-III sprain of the calcaneofibular and tibiofibular ligaments of the ankle and recommends therapy.
 
A physical therapist evaluates him for 24 minutes, spends 24 minutes on soft-tissue and joint mobilization and management of swelling, and spends 12 minutes instructing the patient on exercises he can perform to increase mobility and reduce swelling. The total time equals 60 minutes. Which codes would you choose?
 
Answer: For the diagnosis, you should report 845.02 (Sprains and strains of calcaneofibular [ligament]), 845.03 (Sprains and strains of tibiofibular [ligament]), E885.4 (Fall from snowboard), and E849.4 (Place for recreation and sport).
 
Then you should use 97001 to reflect the evaluation. You should report two units of 97140 for the manual therapy technique (24 minutes documented) and one unit of CPT 97110 for therapy procedure (12 minutes documented).
 
Scenario 2: The same patient progresses with subsequent visits. The physical therapist provides 14 minutes of manual therapy and introduces a  biomechanical ankle platform system (BAPS) for ankle strength and mobility. The physical therapist also performs 10 minutes of neuromuscular retraining and, for 20 minutes, uses ankle strapping to address instability and positioning. How should you code this?
 
Answer: You should report one unit of 97140 (14 minutes documented), one unit of 97112 (Therapeutic procedure, one or more areas, each 15 minutes; neuromuscular re-education of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities) (10 minutes documented), and 29540 (Strapping; ankle and/or foot). The code description for 29540 does not include a time parameter).