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?

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.