Obviously, there’s been quite a buzz surrounding ICD-10; and providers throughout the country are making a tremendous effort to figure out exactly how the transition is going to affect us all. And just like a winged—and busy—bug that won’t stop whizzing past your ear, the noise isn’t likely to die down anytime soon. And that’s for good reason: the ICD-10 transition is a big one, and there are many factors rehab therapists have to consider when coming up with a plan to properly prepare their practices. That’s because depending on the practice’s specialty, payer mix, and clinic setting, ICD-10 implementation has the potential to leave providers singing a variety of tunes—not all of them ending on a positive note. And to make matters even more complex, much of the preparation responsibility falls in the hands of payers.

But what happens when your business caters mainly to direct access patients? If you see a high percentage of self-referred patients, payers might not be on the top of your list of concerns; but they shouldn’t be buried at the bottom, either. And although direct access patients seek treatment without a prior referral, they still may submit bills to their insurances directly; your practice might even be doing so on their behalf. So, what does that mean for you?

WebPT + Billing Software - Regular BannerWebPT + Billing Software - Small Banner

Code Accurately

Even when you don’t have a referral diagnosis, you still must diagnose specifically and accurately, taking your clinical judgement into account. To ensure you land on the most accurate diagnosis, ask yourself:


Who is this patient? Is he or she new to your practice?


What am I seeing this patient for? What happened to this patient to cause his or her present condition?


If you are treating a patient who has suffered an injury, consider where the injury occurred. (In addition to adding an external cause code to designate the location where the injury happened, be sure to select a diagnosis code that accounts for the anatomic site of the injury in the most specific way possible.)


When did the injury occur? Is the patient in the active phase of treatment, or is he or she healing or recovering from the injury or condition (i.e., can you apply a seventh character, and if so, have you selected the appropriate option)?


Why is the patient seeking rehab therapy? Think in terms of causation: rather than simply coding for knee pain, for example, think about what actually caused the knee pain (i.e., the underlying condition).

After you’ve answered those questions, you’ll have the information you need to start your code search. And with ICD-10, it’s more important than ever that you use your clinical judgment to find the most accurate and complete codes. These codes will, in turn, paint the medical-necessity picture for your payers. Speaking of medical necessity, as I mentioned above, some diagnosis codes require a seventh character to designate treatment phase (for more information on that, check out this blog post). According to the experts with whom we’ve consulted, for direct access patients, PTs would use the seventh character "A" for initial evaluations. After that, though, the answer is not so cut-and-dried. Per CMS, "The 7th character for 'initial encounter' is not limited solely to the very first encounter for a new condition. This 7th character can be used for multiple encounters as long as the patient continues to receive active treatment for the condition." This resource goes on to say: "The key to assignment of the 7th character for initial encounter is whether the patient is still receiving active treatment for that condition."

So, it seems the words "initial" and "subsequent" don’t only relate to the number of practitioners the patient has already seen or the number of visits the patient has logged at a specific practice. It’s really about the phase of treatment the patient is in. Again, clinical judgement is the name of the ICD-10 game, and at the end of the day, it’s up to you to determine the most accurate code.

Take Responsibility

I might sound like a broken record with all this talk about clinical judgment, but I really can’t emphasize enough just how crucial it is to your ICD-10 success. Narrowing down your codes might not seem like an easy feat, but if you code to the best of your ability—and provide documentation that supports your selections—this process shouldn’t be as troublesome as you might anticipate. Sure, an EMR will certainly help you select the most complete and accurate code—but your software should not be your crutch. You are, after all, the healthcare professional—and you have the ability to prove the medical necessity of your care. It just takes some time, attention to detail, and effort to select the most accurate patient diagnosis codes—not simply the codes that will get you paid. Furthermore, it’s imperative that you have thorough, defensible documentation to back up your diagnoses—regardless of whether your patients come to you with physician referrals. I’m confident that with the help of the resources you have at your disposal, you can select diagnosis codes for your direct access patients just as expertly as you can for those referred to your practice. And as always, if you determine the patient’s condition is outside your scope of practice, then refer out; this holds true now as much as it will come October 1.

Hit the Books

As you dig into ICD-10, you might find that the wealth of knowledge you have in your mind just isn’t enough to get you to the most accurate code in every single case. That’s to be expected. But you don’t have to be afraid. With the help of your EMR and a quality, PT-specific coding book, you should be able to, at the very least, come up with the ICD-10 codes that you’ll use most often in your practice. To do that, I recommend compiling a list of your clinic’s top 20 ICD-9 codes and finding their ICD-10 equivalents using the process explained in this blog post. That should give you a solid base in code set navigation. Plus, you’ll end up creating a tool that will be very useful to your entire clinic when the transition happens. On the topic of coding books, you might be wondering what book is best for PTs. Funny you should ask; we suggest purchasing Instacode: ICD-10 Coding for Physical Therapy. Want more coding-book bang for your buck? If you’re a WebPT Member, you can purchase the book through the WebPT Marketplace at a discounted rate (and I highly recommend that you do).

Whether you’re concerned about direct access or not, swatting at the ICD-10 transition won’t make it (or the noise) go away. It’s time to jump in, get out the electric fly swatter, and prepare your practice to squash your concerns about the changes that lie ahead.



Need some more guidance? WebPT Founder and COO Heidi Jannenga and coding and compliance expert Rick Gawenda are teaming up to host an ICD-10 bootcamp webinar this month. Don’t worry; they won’t make you drop and give them 20. However, they will run you through the paces when they cover specific (and complex) coding examples for PTs, OTs, and SLPs. But don’t wait to register; we already have more than 2,000 attendees confirmed to join us. Click here to reserve your spot.

  • ICD-10 Open Forum Image

    webinarOct 5, 2015

    ICD-10 Open Forum

    On October 1, the US officially said RIP to ICD-9 and brought ICD-10 to life. For some of you, the transition might’ve been all sugar and spice—a real treat. But for many others, the switch to the new code set might’ve left you feeling overwhelmed, tricked, or even a bit scared. At the very least, you might be haunted by some lingering questions. That’s where we can help. We’ve brewed a cauldron filled to the brim with …

  • The Ultimate ICD-10 FAQ: Part Deux Image

    articleSep 24, 2015 | 16 min. read

    The Ultimate ICD-10 FAQ: Part Deux

    Just when we thought we’d gotten every ICD-10 question under the sun, we got, well, more questions. Like, a lot more. But, we take that as a good sign, because like a scrappy reporter trying to get to the bottom of a big story, our audience of blog readers and webinar attendees aren’t afraid to ask the tough questions—which means they’re serious about preparing themselves for the changes ahead. And we’re equally serious about providing them with …

  • Dawn of the ICD-10: Life in the Post-Transition World Image

    articleOct 28, 2015 | 5 min. read

    Dawn of the ICD-10: Life in the Post-Transition World

    Some of you might remember all of the hype around Y2K. Rumors and speculation were abuzz, and there were people who thought all hell was going to break loose when the clock struck midnight on January 1, 2000. And then—dun, dun, dun—nothing happened. The Hyperbolic Hype The lead-up to October 1 was similar in many respects, albeit on a much smaller scale. People all over the healthcare community were freaking out about the unknown; some large practices …

  • ICD-10 Crash Course: Last-Minute Training for PTs, OTs, and SLPs Image

    webinarSep 2, 2015

    ICD-10 Crash Course: Last-Minute Training for PTs, OTs, and SLPs

    It’s officially here: the last month before all HIPAA-eligible professionals must switch to the ICD-10 code set. As the regret of procrastination washes over many of those professionals, they’re scrambling to ready themselves and their practices for the big switch. If you, like so many other rehab therapists, find yourself asking, “ICD-what?” then you’re in dire need of straightforward training—stat! Otherwise, you could leave your practice vulnerable to claim denials after October 1. Join us at 9:00 …

  • The Complete PT Billing FAQ Image

    articleMay 24, 2016 | 25 min. read

    The Complete PT Billing FAQ

    Over the years, WebPT has a hosted a slew of billing webinars and published dozens of billing-related blog posts. And in that time, we’ve received our fair share of tricky questions. Now, in an effort to satisfy your curiosity, we’ve compiled all of our most common brain-busters into one epic FAQ. Don’t see your question? Ask it in the comments below. (And be sure to check out this separate PT billing FAQ we recently put together.) Questions …

  • Beware of ICD-10 Shortcuts: The Case Against One-to-One Crosswalking Image

    articleFeb 24, 2015 | 7 min. read

    Beware of ICD-10 Shortcuts: The Case Against One-to-One Crosswalking

    ICD-10 is inherently more sophisticated and specific than ICD-9, but that doesn’t necessarily mean it’s more complicated. So, why are healthcare professionals pulling their hair out over the mandatory transition to these new codes? Because learning ICD-10 is like learning a new language. If we were going into this with a clean slate–like a newborn babe—perhaps it wouldn’t be so tough to learn the language. Unfortunately, though, the US healthcare industry has relied on ICD-9 codes for …

  • Physical Therapy Billing for Beginners, Part 1 Image

    articleJul 16, 2017 | 5 min. read

    Physical Therapy Billing for Beginners, Part 1

    Of course, you got into physical therapy to help people—not to rake in the dough. But in order to do the former well, you’ve also got to know how to make a profit—and that requires billing for your services. If you’re new to physical therapy, you might be feeling a little overwhelmed by the prospect, so here are a few things to remember about billing for physical therapy services—the basics, if you will. (Keep in mind that …

  • ICD-10 FAQ Part 4 Image

    articleNov 3, 2015 | 5 min. read

    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 …

  • A Farewell Ode to ICD-9 Image

    articleSep 30, 2015 | 2 min. read

    A Farewell Ode to ICD-9

    As the hours count down It’s hard to believe That we’ve finally made it To ICD-10 Eve Our journey to get here Hasn’t been without strife As the US has clung To ICD-9 for dear life Letting go can be hard And change can be tough But in the modern medical world ICD-9 just isn’t enough Unlike a fine wine That gets better with time ICD-9 has aged poorly— It’s way past its prime Sure, we’ll always …

Achieve greatness in practice with the ultimate EMR for PTs, OTs, and SLPs.