ICD-10 Coding Example: Occupational Therapy

Oh, ICD-10, let me count the ways I love thee. Okay, so maybe you’re not going to wax poetic about the World Health Organization’s updated—and much larger—International Classification of Diseases, but switching to a new code set isn’t the end of the world, either. After all, just because something (ahem, ICD-9) is familiar, it doesn’t mean it’s the best option. In fact, when it comes to code sets, bigger is better. But that also means there’s a lot to learn. To help you get acquainted with ICD-10, we’ve put together an example of what occupational therapists are in for after the switch on October 1, 2015:

Down syndrome (meiotic)

The Patient

Patient is a 7-year-old male with Down syndrome (meiotic). The child presents with:

• Generalized muscle weakness
• Abnormal posture
• Difficulty walking

The Codes

Primary Code

Additional Codes

These codes indicate the reasons for outpatient therapy:

• R26.2 for the difficulty walking or R26.89 for other abnormalities of gait and mobility
• M62.81 for generalized muscle weakness
• R29.3 for abnormal posture

The Description Synonyms

Although this scenario is as cut-and-dried as possible, you’ll still need to use your best clinical judgement to determine whether you should code for R26.2 (difficulty walking) or R26.89 (other abnormalities of gait and mobility). Through your evaluation, you’ll discover that one of these two codes better describes the reason for the patient’s disordered movement. How are they different? Glad you asked. Each code has its own synonyms that can help you make your selection:

Difficulty walking

The description synonyms for R26.2 are:

1. Difficulty walking
2. Walking disability

Other abnormalities of gait and mobility

The description synonyms for R26.89 are:

1. Cautious gait
2. Gait disorder due to weakness
3. Gait disorder, painful gait
4. Gait disorder, weakness
5. Gait disorder, postural instability
6. Gait disorder, multifactorial
7. Toe walking and toe-walking gait
8. Limping/limping child

The Summary

See? Coding for ICD-10 isn’t as difficult as it seems. But adjusting to these new codes will still take time and training. Need to know how to locate ICD-10 codes in the tabular list—or interested in seeing how you can select ICD-10 codes in WebPT? Register for our webinar to reserve your spot for our ICD-10 Bootcamp on August 31 (box jumps and pop squats not required). During this free, 90-minute online webinar, we’ll offer step-by-step guidance on how to code for this example—and ones that are even more complex. With our help, you’ll be ready before you know it.