Health Information Management

Q&A: Coding from physical therapists' notes

JustCoding News: Outpatient, January 27, 2010

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QUESTION: Though we are not permitted to code from nurses’ notes, are we permitted to code from a physical therapist's notes? Specifically, when the outpatient physician order states “Status: Post-surgery for rotator cuff repair,” and the physical therapist documents “joint pain,” can we code from the therapist’s notes?

ANSWER: This has to do with legalities and individual state licensing to practice.

A coder may code from nurses’ notes with regard to procedures and services, but not for diagnoses. This is because legally, nurses are not licensed to diagnose patients. This is also the reason nurses’ notes are not acceptable for determining present on admission indicators either. However, nurses’ notes can legally document procedures and services because typically, they are the professionals who perform these activities. As long as they are working within the limitations of your state laws as to what they are legally permitted to do, their notes are valid for supporting codes reporting those activities.

These requirements also apply for physical therapists. Yes, coders may code procedures and services from physical therapists’ notes. They are licensed by the state to perform certain activities. Therefore, their notes are valid for those activities, typically including procedures, services, and treatments. If your state permits physical therapists to diagnose patients, then coders may also use their notes to support coding those diagnoses.

However, generally state laws only permit physicians to diagnose patients. For this reason, only physicians’ notes—not physical therapists’ notes—are permitted to support diagnosis codes. Therefore, in your example, the pain should be considered a symptom of the post-surgical status, and you would not be able to report this as a separate diagnosis.

In this specific case, the diagnosis code reporting medical necessity for the physical therapy is still the “status post-surgery” code. The pain reported by the therapist is an expected symptom of the patient’s current diagnosis.

Editor’s note: Shelley C. Safian, MAOM/HSM, CCS-P, CPC-H, CHA, of Safian Communications Services in Orlando, FL, answered this question. She is a senior assistant professor who teaches medical billing and insurance coding at Herzing University Online in Milwaukee, WI. E-mail her at ssafian@embarqmail.com.

This answer was provided based on limited information submitted to JustCoding.com. Be sure to review all documentation specific to your own individual scenario before determining appropriate code assignment.



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