Wiki Physical Therapy Diagnosis Coding

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amneske

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Good Morning!

I am trying to assist my hospital with some physical therapy diagnosis coding. If a patient comes in with chronic low back pain due to lumbar spondylolisthesis do you add the diagnosis code for the lumbar pain since that is the reason for treatment by physical therapy OR the spondylolisthesis since that is the cause of the pain even though they are not specifically treating that?

Thank you!
 
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I would code just lumbar spondylolisthesis, since low back pain is a sign/symptom and inherent to spondylolisthesis.
 
Chronic pain G89 excludes lumbar region pain M54.5-M54.59 So I wouldn't use chronic pain. I also agree with parcoeliz that the low back is a symptom of the spondylolisthesis
 
amneske said:
Good Morning!

I am trying to assist my hospital with some physical therapy diagnosis coding. If a patient comes in with chronic low back pain due to lumbar spondylolisthesis do you add the diagnosis code for the lumbar pain since that is the reason for treatment by physical therapy OR the spondylolisthesis since that is the cause of the pain even though they are not specifically treating that?

Thank you!
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Hi Amneske
I have coded for physical therapy at my hospital and audited this service for an insurance copany. Here are some tips....ensure the provider describes the pain and which area it is right left lower ETC Use modifiers RT LT or 51 if necessary. Add the number of minutes on the record for hot pack, massage, ETC in the dated medical documentation. Adding chronic pain is a good idea from the provider in the record and on dx code assessment must be from the provider. If these words are not added cannot use the G89.29 dx code. This should be listed under the painful body part which has ongoing chronic pain on the claim. Central pain syndrome is differ than G89.29 Other chronic pain. Also the provider should be listing this in his notation or as dx code. .The dx blocks ranged most are M47, M54.2 and M54.2 blocks, M19 and M16 define osteoarthritis for certain areas. If the pain is due from an external cause such as: car accident, fall from tree or stairs add that in and DATE of injury if given to you. Also check out dx block X50 for repetitive posture or movement cause muscle aches and pains. Use the Z code when necessary. Check block R29.898, Also areas of pain R10 block match in med record. Muscle twitching is dx R25.3, Muscle spasm M62.83, M25.5 stiffness of certain body area. Pain is listed in dx blocks of M25 and M79. Trigger fingers M65.3 Muscle weakness M62.81 is better than R53.1. Use personal history Z dx codes deemed according to patent past muscle problems and follow up can be Z09, Z47, and Z74.09 Reduced mobility. Check out dx Z73.6 and Z13.82. Always use definitive dx first on claim then other dx and Z code last UNLESS it is first listed encounter dx code. Check out the ICD10 manual index for further dx codes the provider may use. And can go to the CMS web site tell you with certain CPT codes which dx are permissible to bill. I hope this data helps you.:)
Lady T;)
 
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