Wiki ICD 10-Episode of Care

[deansmommy4]

Let's say an orthopedist sees a patient for an injury, and surgery is not necessary at this point. The patient wants physical therapy first. All of these physical therapy visits, and ortho visits are in the 'active treatment' stage, so both providers will be using initial encounters for the visits. Correct?

Then after a few months of no improvement, patient decides to go further with surgery. after the surgery, all other care is subsequent, correct?

The only time physical therapy would be subsequent is post surgery. correct?

I am finding different answers everywhere. Please help.

Thank you!!

 

[mitchellde]

Let's say an orthopedist sees a patient for an injury, and surgery is not necessary at this point. The patient wants physical therapy first. All of these physical therapy visits, and ortho visits are in the 'active treatment' stage, so both providers will be using initial encounters for the visits. Correct?

Then after a few months of no improvement, patient decides to go further with surgery. after the surgery, all other care is subsequent, correct?

The only time physical therapy would be subsequent is post surgery. correct?

I am finding different answers everywhere. Please help.

Thank you!!

If the injury is a fx that requires no intervention except immobilization and PT then the immobilization is the active treatment. The fx would be in a healing state at that point so the PT would be subsequent with routine healing. If the fx does not heal as expected and surgery is decided on then it would need to be documented as delayed healing or non union but either way it is still subsequent. Pt is not active treatment for a fx. A decision for surgery weeks later is also not active treatment.

 

[deansmommy4]

If the injury is a fx that requires no intervention except immobilization and PT then the immobilization is the active treatment. The fx would be in a healing state at that point so the PT would be subsequent with routine healing. If the fx does not heal as expected and surgery is decided on then it would need to be documented as delayed healing or non union but either way it is still subsequent. Pt is not active treatment for a fx. A decision for surgery weeks later is also not active treatment.

What if it is not a fracture? like a partial tear or something..

 

[mitchellde]

What if it is not a fracture? like a partial tear or something..

I would need to see the note but like a rotator cuff tear managed conservatively with PT. the strapping in the Otto office is the active tx, the PT is aftercare during the healing phase so it is still subsequent.

 

[deansmommy4]

I would need to see the note but like a rotator cuff tear managed conservatively with PT. the strapping in the Otto office is the active tx, the PT is aftercare during the healing phase so it is still subsequent.

Thank you very much for your help.

 

[deansmommy4]

I would need to see the note but like a rotator cuff tear managed conservatively with PT. the strapping in the Otto office is the active tx, the PT is aftercare during the healing phase so it is still subsequent.

Ok Debra- so it is the initial encounter for the patient. no strapping is done. provider documents PT for the tear and meds. pt goes to PT, comes back to ortho dr. 2 weeks later. is that a subsequent or initial for the dx? if it is subsequent, then at what point does the active treatment end, when the doctor is not technically performing treatment?? and if months down the road, provider decides surgical treament in necessary, its either subsequent or sequela depending on documentation. right?? am i correct?

thanks!