physical therapy diagnosis and documentation tips 1 · physical therapy diagnosis and documentation...

Physical Therapy Diagnosis and Documentation Tips

© Gentiva® Health Services, 2005 Pamela Teenier and Claire Gold PTDiagDocTipJA.doc-rev01/08

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This tool is designed to assist the Physical Therapist in consultation with the physician, in the selection of an appropriate diagnosis according to Medicare coverage guidelines. The documentation tips will add extra support in the record for the diagnoses and help to prevent down coding or denials. Medical Review by the Intermediary will focus on medical necessity and skilled services provided on each visit.

ICD- 9 Code Diagnosis Rationale Documentation Tips

780.79

Generalized Weakness

Appropriate for a patient that is weak with loss of strength and energy following an illness or hospitalization with loss of function or mobility.

PT evaluation should include the patient’s specific level of function and physical limitations that require skilled therapy services. Medicare will not pay for services to restore strength and endurance the patient may have regained on their own post hospitalization.

799.3

Debility A general non-specific diagnosis that is appropriate to use for someone that is frail and weak due to old age and feebleness when establishing a home exercise program with only limited number of visits covered.

PT evaluation should include the patient’s specific decreased level of function and physical limitations. The home exercise program should be designed to return patient to the maximum level of function. Include in the documentation the patient’s ability to follow through with a return demonstration of the exercise program.

728.2

Muscle Wasting and Disuse Atrophy NEC

Only used when therapy is concentrating on specific muscle groups that have atrophied. For example hamstring muscles that have atrophied as a result of being immobilized in a cast. Appropriate when the physician indicates amyotrophia NOS or myofibrosis and the treatment of these conditions is the main focus of the POC. Not an appropriate diagnosis to use for a patient that has muscle atrophy due to the aging process, poor nutrition and decrease in activity.

Document the specific muscle groups involved that have a measurable decrease in size or have had a prolonged period of inactivity such as with immobilization. Include the patient’s progress toward short term and long term goals to restore prior level of function and mobility.

Document circumferential measurements to indicate difference between limbs – muscle wasting, for example in comparison to the opposite side.



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728.87

Muscle Weakness

This diagnosis can be used for significant muscle weakness when the therapy evaluation shows 2/5 or 3/5 muscle weakness. A 3/5 weakness would indicate the need for therapy to establish a program It would be unusual that a therapy threshold would be needed to carry out the plan. 4/5 muscles weakness would not be adequate indication for the use of this diagnosis.

Appropriate diagnosis following a hospitalization for general decrease in muscle strength, not generalized weakness.

Objective tests should be documented that demonstrate the muscle weakness. POC should be directed toward establishing a home program to correct the weakness when the patient has a significant rehabilitation potential. Documentation must show why the skills of a therapist are necessary to carry out the plan. Document changes in interventions and changes in the types of exercises to support the need for therapy. Include progress toward short term and long term goals.

719.7

Difficulty Walking –(without surgical repair of bone or joint)

Appropriate diagnosis when the patient does not have an abnormal gait but has deficits in mobility.

Documentation for HEP and teaching must be clear and specific to the patient needs such as safety or use of equipment. Avoid repetitious documentation that may be reviewed as maintenance care that could have been provided by the family or home health aide, such as “Patient walked 100 feet today and goal for next visit is 150 feet.”

719.7

Difficulty Walking with Alzheimer’s Disease

Difficulty walking is an appropriate diagnosis for an Alzheimer’s patient that has had a decline in the ability to ambulate. Alzheimer’s disease would then be included as a secondary diagnosis. The determining factor of whether the therapy plan requires the skills of a therapist or should be taught to family or caregivers, depends on the patient’s cognitive status including level of motivation and ability to remember and follow through with therapy instructions toward goal achievement.

Document the appropriate teaching and explanation of the HEP to the patient/caregiver. Visits that do not document the patient’s continued progress may be denied for not reasonable or necessary when potential for further improvement cannot be determined.



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**781.2

Abnormality of Gait for conditions unrelated to surgical interventions

Appropriate when the specific gait disturbance is identified such as stepping, ataxic, paralytic, spastic or staggering gait. This diagnosis is used when the condition or symptoms are associated with neurological or musculoskeletal disease process.

Documentation must include the specific gait disturbance identified and the POC interventions address correction of the gait disturbance in the therapy plan and visit notes. In addition the underlying condition or symptom related to a neurological or a musculoskeletal disease must be identified. Not appropriate to use for a patient experiencing only weakness or de-conditioning due to hospitalization or from a spell of illness. Include amount and type of any therapy the patient may have received in a rehabilitation or nursing facility prior to admission to homecare.

**781.2

Abnormality of Gait following joint replacement or fracture

Appropriate to use post-operative with joint replacement or fracture. When PT is the only discipline ordered use V-code 57.1 as the primary diagnosis with abnormality of gait in both M0245 and as a secondary diagnosis. When multiple disciplines are ordered V 54.81 (aftercare following joint replacement or V54.1 aftercare following fracture) would be used as the primary diagnosis (when all disciplines are focused on the post joint or fracture care). Include the surgical procedure on the plan of care to complete a picture of the patient’s status. The medical diagnosis relevant to the surgery is acceptable following hip fracture or knee/hip joint replacement, but may be included as a secondary diagnosis after other relevant diagnoses are included.

The underlying condition requiring therapy would be included on the POC as a secondary diagnosis along with listing the surgical procedure to explain the patient’s status.



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**434.91 Cerebral Artery Occlusion with cerebral infarction

Use following acute CVA if patient is coming direct from acute care institution with goals not yet met. Stay with 434.91 until goals are met in homecare.

Include history of occlusion with infarction and the amount and type of therapy the patient has already received in the acute care institution. Therapy notes should show progress and changes in the plan of treatment that demonstrates patient progression toward goal achievement.

**436 Acute but ill defined, cerebrovascular disease

The use of this code changed 10/04. It is now used primarily for cerebral seizures It now excludes ischemic, embolic, hemorrhagic and thrombotic CVA and strokes. It also excludes postoperative CVA (997.02) and unspecified CVA (434.91).

Make sure that clinical record clearly documents that a CVA did not occur. Include any specific information on the cerebral seizure. This code will be used very infrequently due to the change in definition.

438.0 or 438.XX

Late effects of cerebrovascular disease

If the patient has previously received therapy services and was discharged with goals met. Indicates conditions in categories 430-437 as the cause of late effects. Late effects may occur soon after the initial condition or arise later after healed. For a patient with late effect with hemiplegia, it is not appropriate to also list abnormal gait as it is inherent with hemiplegia to also have an abnormal gait. Coding guidelines indicate to only use symptom codes (like abnormal gait) when a definitive diagnosis is not known.

Document information on previous therapy received and goals attained. Be specific as to the type and severity of late effect. Therapy notes should show progress and changes in the plan of treatment that demonstrates patient progression toward goal achievement.

997.02 Iatrogenic cerebrovascular infarction or hemorrhage

A CVA hemorrhage or infarction that occurs as a result of medical intervention. Also code a secondary code from the code range 430-432 or from subcategories 433 or 434 with a 5th digit of “1” to identify type of hemorrhage or infarct. Do not use with 436.

Include history of hemorrhage or infarction and the amount and type of therapy the patient has already received in the acute care institution. Therapy notes should show progress and changes in the plan of treatment that demonstrates patient progression toward goal achievement.



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Some V Codes may be used as primary or secondary diagnoses. When the use of a V code replaces a case mix diagnosis M0245 must be completed on the OASIS, or it will result in decreased reimbursement. After December 1, 2005 V57 codes can only be used as primary diagnosis in M0230 and cannot be used in M0240.

V Codes

V54.1X

Fifth digit indicates site of fracture

Aftercare for healing of traumatic fracture

Can be used as a primary or secondary diagnosis

Use an aftercare code for services following a fracture (closed reduction or open reduction with internal or external fixation). Include the surgical procedure on the plan of care to denote the recent surgery. The use of a V-code may replace a case mix diagnosis such as abnormality of gait as the primary diagnosis following certain types of fractures (for example hip or leg fractures). An aftercare code may be the primary diagnosis when multiple aspects of the patient care are being addressed or multiple disciplines are involved with the care. If multiple disciplines are ordered with the focus of care related to the fracture, code as follows: M0 230 V54.1x, and 781.2 in both M0240 and M0245. When physical therapy is the only discipline ordered, place the case mix diagnosis in M0245 for the correct reimbursement and also in M0240. For example: M0230 – V57.1, M0245 – 781.2 (Abnormality of Gait), M0240 – 781.2, V54.1X (becomes a secondary diagnosis)

Therapy notes should show progress and changes in the plan of treatment that demonstrates patient progression toward goal achievement. Include amount and type of therapy patient may have received in a rehabilitation or nursing facility prior to admission to homecare. The amount of pain and interventions to relieve pain should be noted on each visit note. Include documentation of specific gait disturbance identified when abnormality of gait is used in M0245 to obtain case mix points. The therapy plan must address the gait identified.



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V Codes

V54.2X

Fifth digit indicates site of fracture

Aftercare for healing pathologic fracture.


Performing care following a fracture. May involve closed reduction or open reduction with internal or external fixation or splinting. Same logic as above when PT is the only discipline providing the care. Use the same coding examples (substituting V54.2X) and sequencing when the V code replaces a case mix diagnosis or other disciplines involved in care.

Therapy notes should show progress and changes in the plan of treatment that demonstrates patient progression toward goal achievement. Include amount and type of therapy patient has received in a rehabilitation or nursing facility prior to admission to homecare. Amount of pain and interventions to relieve pain should be noted on each visit note. Include documentation of specific gait disturbance identified when abnormality of gait is used in M0245 to obtain case mix points. The therapy plan must address the gait identified.

V54.81 Aftercare following joint replacements

Can be used as a primary or secondary diagnosis.

Use additional V code 43.6X to designate the joint replaced. The use of V-codes may replace abnormality of gait as the primary diagnosis for certain joint replacements (for example hip or knee replacements). Include the surgical procedure on the plan of care to complete a picture of the patient’s status. V54.81 is appropriate when PT and nursing are ordered even if nursing is only for PT/INR tests. In that scenario the coding would be V54.81 in M0230 and M0240 would have V43.6X (joint replaced site) 781.2 (which would also be used in M0245), and V58.83 (encounter for therapeutic drug monitoring). If PT is the only discipline ordered V57.1 would be the primary diagnosis in M0230 followed by V54.81, V43.6X, and 781.2 (which would also be used in M0245).

Therapy notes should show progress and changes in the plan of treatment that demonstrates patient progression toward goal achievement. Include amount and type of therapy the patient has received in a rehabilitation or nursing facility prior to admission to homecare. The amount of pain and interventions to relieve pain should be noted on each visit note. Include in documentation the specific gait disturbance identified when abnormality of gait is used in M0245 to obtain case mix points. The specific gait must be addressed in the therapy plan and visit notes.



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V Codes

V54.89 Other orthopedic aftercare

Best to use either V54.1X or 54.2X when possible since they are more specific.


Performing care for healing fracture, not otherwise specified. (Example: This code is used for pin care) The primary diagnosis should reflect the services provided with this code as a supplemental code to describe additional services. When the POC only contains PT, V57.1 should be the first code used to justify therapy followed by V54.89 in M0240.

Therapy notes should show progress and changes in the plan of treatment that demonstrates patient progression toward goal achievement. Include amount and type of therapy the patient has received in a rehabilitation or nursing facility prior to admission to homecare. Documentation must include the specific gait disturbance identified when abnormality of gait is used in M0245 to obtain case mix points. The specific gait must be addressed in the therapy plan and visit notes.

V57.1 Physical Therapy care involving the use of rehabilitation procedures

Can only be used as a primary diagnosis

Use as a primary diagnosis when therapy is the only discipline. When multiple disciplines are involved, code the underlying condition or injury as primary and do not use the V57.1 code. Includes therapeutic and remedial exercises, except breathing. When V57.1 is used include additional code to identify underlying condition that is driving the need for rehab care.

PT evaluation should include the patient’s specific decreased level of function and physical limitations to demonstrate the need for therapy services. Include amount and type of therapy patient has received in a rehabilitation or nursing facility prior to admission to homecare. Avoid repetitious documentation that may be viewed as maintenance care that could have been provided by the family or home health aide, such as only an increase in the number of feet ambulated or additional repetitions of established exercises.



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V Codes

V57.81 Orthotic Training


Performing orthotic and gait training in the use of artificial limbs. Add a secondary code from V49.6X-V49.7X group to identify the amputated limb site. Include the surgical procedure on the plan of care to complete a picture of the patient’s status. Use additional code to identify underlying condition. Abnormality of gait may also be appropriate to use in M0245 and as a secondary diagnosis when ambulation is the focus of the plan of care.

Include amount and type of therapy the patient has received in a rehabilitation or nursing facility prior to admission to homecare. Therapy notes should show progress and changes in the plan of treatment that demonstrates patient progression toward goal achievement, including the patient’s compliance and follow-through with prescribed exercises.

V57.89 Other Specified Rehabilitation Training


Performing specified rehabilitation procedures with multiple training or therapy. Use additional code to identify underlying condition. Assign this code when PT, OT and/or SLP are included in the POC. V57.89 may also be used when there is no specific rehab code available (e.g., with pulmonary rehab), but only as a primary diagnosis.

Orders and documentation must support need for skilled therapy intervention. PT evaluation should include the patient’s specific decreased level of function and physical limitations to demonstrate the need for therapy services. Therapy notes should show progress and changes in the plan of treatment that demonstrates patient progression toward goal achievement.

physical therapy diagnosis and documentation tips 1 · physical therapy diagnosis and documentation...

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