Physical therapy ICD-10 codes are used by physical therapists in the United States for billable services.
While any practicing therapist will be familiar with the process of searching for and choosing these codes, many of them have never learned about the structure and purpose of these codes and how to select a code that maximizes the likelihood of insurance covering their services. If you are ready for a primer in physical therapy ICD-10 codes, keep reading to learn more about physical therapy ICD-10 codes and common coding mistakes to avoid.
What are physical therapy ICD-10 codes?
The International Classification of Disease, 10th Revision (ICD-10) is a set of diagnosis, symptom, and procedure codes that physical therapists use daily in their practice. In 2015, physical therapists and all other HIPAA-covered healthcare providers transitioned from the ICD-9 to the current version, ICD-10. Physical therapy ICD-10 contains two code sets: ICD-10 CM and ICD-10 PCS. The PCS code set is used only for inpatient procedures and will not be discussed further in this article. The CM code set, short for Clinical Modification, is used in outpatient and clinical settings in the U.S and will be discussed further here.
The purpose of ICD codes, according to the Centers for Medicare and Medicaid Services, is to promote international comparability in the collection, processing, classification, and presentation of mortality statistics. They identify a medical diagnosis and help insurance companies understand why the care you are providing is medically necessary and therefore, reimbursable. If you are a HIPAA-covered entity, you must submit these physical therapy ICD-10 codes if you are seeking reimbursement from an insurance company. You can select multiple codes that describe the primary condition and symptoms related to the condition but one code will be reported as a primary code.
All physical therapy ICD-10 codes are alphanumeric. They begin with a letter and are always between three to seven characters with a decimal point placed after the third character. The more characters it has, the more specific it is. Each code follows the following structure:
- Characters 1-3 indicate the category of the diagnosis
- Characters 4-6 indicate etiology, anatomic site, severity, or other clinical detail
- Character 7 is an extension value. or example:
- A: Initial encounter (anything related to the care of the initial injury)
- D: Subsequent encounter (anything related to the phase of routine care of the injury while the patient recovers–this usually refers to rehabilitation)
- S: Sequela (other conditions that may result from the presence of the primary condition)
Note, for fracture care, there are several more extensions (for example P, G, and K, which signify malunion, delayed healing, or nonunion for a subsequent encounter)
| Condition | Code |
|---|---|
| Disorder of continuity of bone | M84 |
| Stress fracture | M84.3 |
| Stress fracture, shoulder | M84.31 |
| Stress fracture on right shoulder | M84.311 |
| Stress fracture, right shoulder, subsequent encounter for fracture with routine healing | M84.311D |
When selecting physical therapy ICD codes, the code with the highest number of applicable characters should be chosen, at least on the first visit. Greater specificity with your physical therapy ICD-10 code is more likely to lead to reimbursement but it should always be supported by the patient’s medical record and clinical knowledge of the patient’s condition.
Common physical therapy ICD coding mistakes to avoid (mistakes that could cost you)
In today’s world of electronic health records, finding a physical therapy ICD-10 code is often as simple as typing words in a search box. You will be immediately presented with a list of codes related to the condition for which you are searching. Charting software makes it easy to find relevant physical therapy ICD-10 codes. What is not as easy, is understanding which code to select because the most obvious code is not necessarily the one that will best guarantee reimbursement by an insurance company.
While common physical therapy ICD-10 coding mistakes will increase the likelihood of claims being denied even when your treatments are medically necessary and should be covered by the patient’s insurance plan. Let’s take a look at some of these coding errors.
Non-billable, Nonspecific codes
Since specificity is king in physical therapy ICD-10 codes, many of the most obvious and simplest codes are not specific enough to be billable as a primary code from an insurance perspective. You can find a list of over 20,000 codes on the free ICD10 Data website that are considered nonspecific, of which you want to be aware. Whenever you look up a code on this site, a green or red arrow (as well as a description) will indicate if it is specific enough to be billable as a primary code or not.
| Condition | Code |
|---|---|
| Paraplegia | G82.2 |
| Spastic hemiplegia | G81.1 |
| Traumatic arthropathy, shoulder | M12.51 |
| Recurrent subluxation of the patella | M22.1 |
| Osteoarthritis of the hip | M16 |
In these cases, the nonspecific code will have codes beneath it that contain a greater level of detail and you should look for one of these instead.
“Unspecified”, “not-otherwise-specified”, “not elsewhere classified”
Examples:
- M25: Other joint disorder, not elsewhere classified
- M71.5 Another bursitis, not elsewhere classified
These physical therapy ICD-10 codes can be found for a whole host of medical conditions. The clue to these codes is they will include the words “unspecified”, “not-otherwise-specified”, and “not elsewhere classified”. In some cases, this code may apply to the case you are treating, but not be used as the primary diagnosis code if there are more specific codes that can be used instead. There are some codes like “Unspecified abnormalities of gait and mobility” that are considered specific enough but you can reference the ICD10 Data Website to double-check.
Multiple Site Diagnoses
Example: M10.09 Idiopathic gout, multiple sites
In some cases, you may be addressing symptoms or conditions related to multiple sites in the body. For example, when treating a patient with gout in more than one joint or osteoarthritis in several joints. In this case, it might seem appropriate to choose the code M19: osteoarthritis, to indicate that it exists in more than one place. This, however, is considered a nonspecific code and should not be used for reimbursement purposes.
Instead, when possible use the physical therapy ICD-10 code that includes “multiple sites”. For example, M43.19: Spondylolisthesis, multiple sites in the spine. If a “multiple sites” option is not available for that diagnosis, you should include a physical therapy ICD-10 code for each body site involved.
External Cause of Place of Occurrence Codes
- The code Y92 denotes “place of occurrence”
- Example:
- Y92.328: Another athletic field as the place of occurrence of the external cause
External cause codes range from V00-Y99
- Examples:
- W61.62: Struck by duck
- W50.0: Accidental hit or strike by another person
These physical therapy ICD-10 codes can be used during the initial evaluation to increase the specificity of the primary diagnosis. For instance, if you are treating a soccer player who sprained his MCL on the field and came straight to you through direct access, you could use S83.411A (Sprain of medial collateral ligament of the knee, initial encounter) as the primary code and then list W50.0XXA as the external cause (initial encounter) and Y92.328 as the place of occurrence. Typically the external cause and place of occurrence codes would not be reported again during follow-up visits.
Now that we have reviewed the purpose and structure of physical therapy ICD-10 codes and what to avoid, take a look at some common examples for the shoulder and low back and how we can apply these concepts to a couple of real-life coding examples.
Low back pain with sciatic nerve pain resulting from a car accident 2 weeks ago
Codes reported at initial evaluations
| Codes reported at the initial evaluation | Condition/location | Ability to bill |
|---|---|---|
| M54 | Dorsalgia: Low back pain | Too nonspecific to be billable |
| M54.4 | Lumbago with sciatica | Still too nonspecific |
| M54.41 | Lumbago with sciatica, right side | OK to use as primary code |
| V43.52 | Car driver injured in collision with another type car in a traffic accident | Too nonspecific |
| V43.52XD | Car driver injured in collision with another type car in a traffic accident, subsequent encounter | Specific enough |
| Y92.411 | Interstate highways as the place of occurrence of the external cause | Specific enough |
| R26.89 | Other abnormalities of gait and mobility | Used as a synonym for painful gait |
| R53.1 | Weakness of the right leg | Although non-specific, billable |
Codes that could be reported at subsequent follow up
- M54.41: Lumbago with sciatica, right side
- R26.89: Other abnormalities of gait and mobility
- R53.1: Weakness of the right leg
Physical therapy post-left shoulder rotator cuff repair
Time: 3 weeks ago
In this case, the original injury, the rotator cuff repair, is healed by the surgery and you are now providing post-surgical aftercare. Use the Z Code for post-surgical aftercare in combination with codes that describe current symptoms:
- Z47.89: Encounter for other orthopedic aftercare
- M25.512: Pain in the left shoulder
- M62.522: Muscle wasting and atrophy, not elsewhere classified, left upper arm
Understanding and knowing the best physical therapy ICD-10 code is paramount to getting paid for the services you provide. While there are tools to help you look up the best codes, having them at your fingertips in an EHR can save you, precious team.
