ICD-10 Example for OT

Are you an ICD-10 coding expert? Do you feel prepared to take on the complexities that are an inevitable—yet, crucial—component of the new code set? No? Well, not to worry. ICD-10 is certainly complex, and you should take this transition seriously. Still, you shouldn’t let fear (and frustration) get the best of you. With that in mind, what can you do to make the transition smoother? Practice, practice, and well, more practice. Speaking of practice, here’s an occupational therapy coding example from compliance expert Rick Gawenda. Walking through this example should help you fine-tune your coding skills. Here’s the situation:

The Patient

The patient is a 7-year-old female with Down syndrome (meiotic). Her parents have been referred to occupational therapy, because she’s having problems with her posture and walking. She appears to be suffering from muscle weakness. How would you code for this?

The Codes

Primary Code

  • Q90.0, Down syndrome. More specifically, this code indicates the patient’s diagnosis of Trisomy 21, nonmosaicism (meiotic nondisjunction).

Additional Codes

With ICD-10, you should indicate the reason for outpatient therapy whenever possible. In this case, you would use the following codes:

  • 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

You’ll have to use your clinical judgement to determine whether you’d code R26.2 (difficulty walking) or R26.89 (other abnormalities of gait and mobility). During your evaluation, you likely will find that one code is more appropriate than the other. One way to determine which code you should select: review each code’s description synonyms. Here are the description synonyms in this situation:

Difficulty walking. The description synonyms for R26.2 are:

  • Difficulty walking
  • Walking disability

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

The Summary

When all’s said and done, coding to the highest level of specificity requires you to change your mindset. When you account for additional information pertaining to each patient’s condition, you’re able to determine which codes accurately explain the scenario. Feeling better about the transition after reviewing this example? Want to see more examples like this one? Watch WebPT’s free ICD-10 bootcamp webinar. In it, we provide 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 well before October 1.