Posts by Courtney Lefferts

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What is Defensible Documentation, and Why Does it Matter?

I think Julie Andrews was spot-on when she sang the following verse about physical therapists: “When the dog bites, when the bee stings, when you’re feeling sad, you simply remember your defensible documentation, and then you don’t feel so bad.” That is how it goes, right? No? Whoops. Looks like I mixed up some of the lyrics.

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ICD-10 FAQ Part 4

Like the many Land Before Time sequels, the versions of our ICD-10 FAQ keep on-a-comin’. But—unlike those beloved dinosaur tales—I don’t anticipate 12 more versions (plus a TV series) will be necessary to cover what’s to come with ICD-10. Still, the questions continue to roll in—albeit a bit slower than they did a couple of months ago. However, most of the inquiries we’ve received in recent weeks have been super specific. That’s why, our most recent webinar—the ICD-10 Open Forum—included an extended audience Q&A session hosted by Dr. Heidi Jannenga and compliance expert Rick Gawenda. In case you missed it, I’m going to make like Littlefoot and take on some of our most frequently questions from the webinar while chewing on some prehistoric ferns (or something like that):

Where do I find information on state regulations related to ICD-10?

We suggest contacting your payers, as well as consulting your state association’s website/state practice act, to get the most up-to-date, state-specific information.

What’s the difference between R53.1, Weakness, and M62.81, Muscle weakness (generalized)?

According to this resource, M62.81 is typically classified as a disorder characterized by a reduction in the strength of muscles in multiple anatomic sites, or a reduction in the strength of muscles in multiple anatomic sites. R53.1, on the other hand, is a sign or symptom associated with:

  • weakness and diminished or absent energy and strength;
  • debility, or lack or loss of strength and energy;
  • physical weakness, lack of strength and vitality, or a lack of concentration;
  • lack of physical or mental strength;
  • liability to failure under pressure or stress or strain;
  • weakness; and/or
  • lack of energy and strength.

If I shouldn’t use unspecified codes, then why are they even an option?

The unspecified codes exist in case there truly is not another, more specific option available. However, if a more specific option is available, you absolutely should use it.

If a patient experiences muscle weakness in a specific area, should I use M62.81?

The clinical description for M62.81 reads, "A disorder characterized by a reduction in the strength of muscles in multiple anatomic sites." Because this code describes weakness in multiple anatomic sites, it would not be appropriate for weakness that exists in a specific location. As mentioned in our other FAQs, if available, you should always code for the underlying condition causing the muscle weakness first.

Can I list a condition like poor balance as a primary diagnosis?

You should code first for the underlying condition (i.e., what's causing the patient's balance issues). If you can’t determine the underlying condition, ICD-10 code R26.81, Unsteadiness on feet, might be a good option.

What code should I use for difficulty walking? R26.2 or R26.89?

Depending on your evaluation, you might discover the reason behind the disordered movement is best described by one code more than the other. Each code has its own synonyms that can help you make your selection.

For example, this resource explains that the description synonyms for R26.2, difficulty walking are:

  • Difficulty walking
  • Walking disability

The description synonyms for R26.89, Other abnormalities of gait, and mobility are:

  • Cautious gait
  • Gait disorder due to weakness
  • Gait disorder, painful gait
  • Gait disorder, weakness
  • Gait disorder, postural instability
  • Gait disorder, multifactorial
  • Toe walking and toe-walking gait
  • Limping/limping child

Should I code for accidents/incidents that affected my patients in the past?

You cannot—and should not—code for what you don’t know. If you can’t say for certain that the accident/incident directly correlates to the patient’s current condition, don’t code for it.

What if I have a highly-specific clinical coding question, and I can’t find the answer?

We’re happy to answer your questions to the best of our abilities. However, if the example is extremely clinical in nature, we can’t give you a definitive answer. But, we do know of a resource exactly for these types of situations. If you are able to supply supporting documentation for your particular scenario, you can submit your coding questions via this AHA portal.

WebPT-Related Questions

How does WebPT protect providers from making ICD-10 coding errors?

WebPT prompts users to select the most complete code possible and does not allow users to bill incomplete codes. However, you’ll still need to use your clinical judgement to make the proper selection from all of the available codes.

Will WebPT allow providers to use ICD-9 codes for patients with dates of service prior to October 1?

Yes. WebPT automatically recognizes whether the patient should have ICD-9 or ICD-10 codes based on the date of service on the note.

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WebPT Celebrates Global PT Day of Service

Global PT Day of Service is right around the corner—this upcoming weekend, to be exact. What does that day signify? Well, it means that on October 17, 2015, physical therapists all across the globe are joining together to donate their time in service to their local communities. In the spirit of giving, our founder and COO, Dr. Heidi Jannenga—along with a crew of WebPT employees—will join together with students and other physical therapists across the Phoenix valley to make a positive impact on our community.

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Do You Dry Needle?

According to the APTA, many providers consider dry needling “a safe, easy-to-learn, minimally discomforting, and often-effective technique for patients with certain presentations.” Yet, it remains a controversial practice. Much of the concern lies in the fact that this modality involves piercing the skin; many acupuncturists would argue that PTs don’t have the expertise to perform this type of manual therapy.

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The Ultimate ICD-10 FAQ

This ICD-10 FAQ for physical, occupational, and speech therapists covers everything from external cause codes and seventh characters to direct access and dual coding.

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Costly ICD-10 Traps and How to Avoid Them

Imagine you’re playing a game. More specifically: an ICD-10 Rube Goldberg-style game. To win, you have to scurry through a series of stages without getting caught in costly traps. But what happens when you find yourself at the mercy of the swiftly-turning plastic crank? Before you know it, the cage has lowered and you’re out of the game—forever separated from your cheddar.

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ICD-10 Coding Example: Physical Therapy

Have you worked hard throughout the year to train your ICD-10 muscles? Do you feel brainy-buff enough to join the ranks of ICD-10 experts come October 1? If not, you’re not alone. That’s exactly why we’re hosting an ICD-10 bootcamp webinar: To whip you into tip-top-coding shape. I trust that with the help of WebPT founder and COO Heidi Jannenga and coding expert Rick Gawenda, that you, too, can pull up on your coding bar and get to sprinting straight toward a successful ICD-10 transition.

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Direct Access from the Patient’s Perspective

If you’ve been following the WebPT Blog for even a short time, you’re likely aware that direct access to physical therapy is the way of the future—especially now that some form of this patient-centric care exists in all 50 states. That’s why we’ve covered everything providers need to know about direct access, from marketing topics to individual state regulations.

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CEU Shopping Guide

In some social circles, shopping is considered a sport. In others, it’s merely an obligation or simply a pastime. But when it comes to shopping for continuing education units (CEUs), one point most social circles can agree on is that determining the right educational courses is far more important than say, the quest for the perfect pump. That’s because—in most states—earning the right CEUs is mandatory in order to maintain your license.

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