Wiki Question for Medical therapy for school rehab (kindergarten to 1st grade)

[yabutma]

Hello!

I will be coding for a school rehab for kindergarten to 1st graders. They provide medical therapy (speech, occupational and physical). My questions is, which one is primary? Therapy diagnosis or Medical diagnosis (mild cognitive disability, muscle weakness, down syndrome)?

thank you,

Mark

 

[Cynthia Hughes]

diagnosis for medical therapy

Hi,

You will want to follow the ICD-10-CM guidelines for outpatient services. "List first the ICD-10-CM code for the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided. List additional codes that describe any coexisting conditions. In some cases the first-listed diagnosis may be a symptom when a diagnosis has not been established (confirmed) by the physician." Your providers will need to indicate the specific conditions (e.g., delayed development of speech and language) treated at each encounter and then related diagnoses like developmental delay.

I hope that helps.
Cindy