ICD-10 Coding Example for PT

Don’t you just love word problems? We do—so we created a fun ICD-10 word problem just for physical therapists. Don’t worry; we’ve provided the answer, too. Ready to learn how to code for ICD-10? Then, here we go!

The Example

ACL sprain

The Patient

The patient is a 16-year-old male. During his high school soccer game last week, the patient sprained his ACL when his knee came into contact with another player’s leg. He comes to your office without a physician referral and is using crutches for ambulation. He also presents with:

  • Pain, especially while walking
  • Edema
  • Instability in his right knee

The Codes

Primary Codes

  • S83.511A for sprain of anterior cruciate ligament of right knee, initial encounter.
    • Because this is a direct access patient, you’d use “A” as the seventh character.
  • W51.XXXA for accidental striking against or bumped into by another person, initial encounter.
    • This external cause code further describes the factors leading up to the injury.
  • Y92.322 for soccer field as the place of occurrence of the external cause.
  • Y93.66 for activity, soccer.

Additional Codes

These codes indicate the reasons for outpatient therapy:

  • R26.2, Difficulty in walking, not elsewhere classified, or R26.89, Other abnormalities of gait and mobility
  • M25.561, Pain in right knee
  • M25.361, Other instability, right knee
  • M25.461, Effusion, right knee

The Description Synonyms

Did you notice you could code either R26.2 (difficulty walking), or R26.89 (other abnormalities of gait and mobility)? You’ll need to use your patient evaluation and best clinical judgement to determine which code better describes the reason for the patient’s disordered movement. 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

This example has codes for days, so if you’re still a bit confused—or having panicky flashbacks to that dreaded linear algebra class—we get it. That’s why we’re hosting our ICD-10 Bootcamp on August 31. During this free, 90-minute online webinar, we’ll provide a step-by-step explanation on how to locate ICD-10 codes in the tabular list, in the index, and in WebPT. Make sure you register here to reserve your spot.