Occupational Therapy Business Tips
August 28, 2024
ICD-10 codes for occupational therapy are used to describe billable OT intervention options in daily documentation. In 2015, the Centers for Medicare & Medicaid Services (CMS) helped coordinate the replacement of the previous ICD-9 codes with the new International Classification of Diseases-10 (ICD-10) codes. ICD-10 codes are mandatory for healthcare documentation, including records used in occupational therapy practice.
In this article, we will discuss:
ICD-10 coding was initially created by the World Health Organization (WHO) and the National Center for Health Statistics (NCHS) drew from that to design the U.S. version. ICD-10 codes are used by physicians and other healthcare providers, including OTs, to categorize and document diagnoses and medical procedures.
Due to the complexity of ICD-10 coding and occupational therapy’s wide scope of practice, unintentional mistakes are common. Occupational therapists who are new to their practice and unfamiliar with the pre-approved codes for their particular business tend to make errors, the most frequent of which are listed here.
The transition from ICD-9 to ICD-10 codes for occupational therapy occurred almost a decade ago. However, some healthcare settings occasionally neglect to update their coding system. Additionally, well-seasoned occupational therapists may be logging old codes out of habit, especially if codes need to be entered manually.
Since occupational therapists are not licensed to assign diagnoses, ICD-10 diagnostic codes are typically provided by the referring physician. Once those codes are logged using documentation software, some occupational therapists may neglect to assign procedure or treatment codes. Without procedure codes, overseeing physicians and supervisors can’t sign off on OT intervention.
All in all, there are over 150,000 unique ICD-10 codes. Documentation software that forces occupational therapists to enter codes manually increases the likelihood of scrambling similar numbers and letters. A discrepancy of only one letter or number can completely change intended OT interventions.
Several coded diagnoses and symptoms require specific details, such as including a disorder of a specific joint or one side of the body. Some occupational therapists may accidentally omit ICD-10 codes that log those details, which will confuse other healthcare providers who may reference occupational therapy documentation for their own practice.
Lack of training or a simple misclick can lead some occupational therapists to use incorrect codes for prolonged periods of time. This includes ICD-10 diagnosis codes provided by physicians, as well as procedural codes to categorize pre-approved interventions for their particular practice settings.
Faulty documentation software and lack of training can lead to occupational therapists creating incomplete intake forms, evaluations, and treatment notes. This includes omitting diagnostic and procedural ICD-10 codes from occupational therapy SOAP notes, which are mandatory for insurance reimbursement and can help clinics through routine audits.
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Depending on the clinical practice and target clientele, occupational therapists will cycle through dozens, if not hundreds, of ICD-10 codes. The following is a list of commonly-used ICD-10 codes for occupational therapy that may crop up in documentation across healthcare settings.
ICD-10 code R63.3 encompasses several codes, which provide greater detail for reimbursement purposes. Some examples of feeding difficulties include the following:
There are many others, but this code does not cover specific feeding disorders such as anorexia or bulimia, which fall under a different but similar code (R63).
ICD-10 code G54.0 is a billable and reimbursable diagnosis code that is often used for clients with thoracic outlet syndrome. This code is usually grouped together with other codes indicating cranial and peripheral nerve disorders that result in muscle weakness and/or paralysis.
This code is exclusively used for clients from newborn to 17 years of age and is often assigned when there are physical symptoms of delayed motor or speech capacity. This means a child is falling reasonably behind their typically-developing peers in significant areas including walking and talking.
This code indicates paralysis of lower limbs often caused by damage to the spinal cord. However, subcodes may offer greater detail such as paralysis related to stroke or paralysis with a neurogenic bladder. It’s reserved for cases displaying symptoms of severe or complete loss of movement in the legs.
Ataxia refers to loss of muscle coordination, which can result from injuries to the spinal cord, brain, or peripheral nervous system. Clients with Parkinson’s disease or other neurodegenerative disorders may receive this code to proceed with occupational therapy services.
F82 is applicable to clients who may be diagnosed with clumsy child syndrome. Motor symptoms can’t be related to another medical condition (such as spinal cord injury) and must significantly impact activities of daily living. If clients exhibit lack of coordination then an ataxia ICD-10 code may be more appropriate.
M62.81 is commonly used in occupational therapy clinics for clients across the age span, indicating general loss of muscle strength. This excludes disorders such as sarcopenia, which is muscle loss due to the natural aging process. M62.81 may indicate trunk weakness or general muscle weakness after illness or injury.
F88 ICD-10 code offers practitioners the ability to document related interventions for disorders that may not be diagnosable according to national medical and psychological association standards. This includes symptoms of global developmental delays, neurodevelopmental conditions, agnosia, and sensory integration disorders.
Unlike M62.80, ICD-10 code M25.60 indicates joint stiffness as a result of muscle and/or connective tissue instead of general muscle weakness. Joint stiffness can be identified and documented according to a specific joint, multiple joints, or unspecified joint stiffness as a result of illness or injury.
F81.9 is frequently used to indicate unspecified learning disorders that impact academic performance. This means that it’s often suitable for school-based settings that refer children to contracted occupational therapy services. Because of the academic impact, this code is not typically used until a child reaches at least school age.
With the right occupational therapy documentation software, practitioners can assign ICD-10 codes with ease and accuracy to custom templates and forms. ClinicSense offers the best software for occupational therapists in multiple settings, including pay-based clinics. Its customizable occupational therapy SOAP notes are useful for organizing documentation and billing for services.
If you’d like to learn more about what occupational therapists should look for in documentation software, you can take a look through our blog. Or sign up for our occupational therapy software free trial, which can be used with all ICD-10 codes for occupational therapy.
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