Intro To Clinical Reasoning

"Common PT ICD-10 Codes", "Billing Codes", "Evaluation Codes",

Demographics of documentation

• name

• date of service/treatment

• date of birth

• referring physician

• diagnosis

• PT diagnosis

medical diagnosis

focus on the cause of the disease process, illness, or specific injury

PT diagnosis

focuses on the consequences of that disease, illness, or injury

ICD 10 Code

specific alphanumeric codes that classify medical diagnoses for the purposes of billing, insurance, health tracking, and research

who is the ICD 10 published by

WHO

ICD-10 is required for

everyone covered by the HIPPA and ACA

A =

initial encounter

“A” definition

when the patient is receiving active treatment for the condition

D =

subsequent encounter

“D” definition

for encounters after the patient has received active treatment of the condition and is receiving routine care for the condition during the healing or recovery phase

Which types of code do PT’s usually use

D codes (unless seeing a pt. under Direct Access)

S =

sequela

“S” definition

complication or conditions that arise as a direct result of a condition

history of present illness

events that led up to the current epidsode of care

current medical history

facts related to current episode of care

past medical history

review of systems, the important underlying medical history or comorbidities that will come into play but may not be directly related to the current medical event

precautions

weight bearing precautions, isolation precautions, safety or fall risk

medications

list meds here

chief complaint

in their own words, pt. describes what the primary medical condition or sign/symptom that they are concerned about

social history

family status, family geography, employment status, hobbies, recreational activities

social/health habits

smoking, alcohol consumption, recreational drug use, exercise, etc.

barriers to learning/education

level of education, hearing or visual impairment, primary language, etc.

home barriers

includes physical environment and available resources

patient goals

what does the patient want to accomplish in physical therapy in their own words

systems review purpose

scan patient’s body systems for function and dysfunction

system review method

medical screening questionnaire, medical record, interview, or tests

minimal data set (MDS) include

• HR

• BP

• orientation

• communication (ability, affect, language)

• learning style (visual, auditory, reading/writing, kinesthetic)

Cardiovascular systems review

• HR

• BP

• Temp

• Pedal pulses

• SOB

• Chest pain

• arrhythmia

• leg cramps

• edema

pulmonary systems review

• RR

• SpO2

• SOB

• difficulty breathing

• cough

• wheezing

integumentary systems review

• skin color

• temp

• integrity

• texture

• scars

• wounds

musculoskeletal systems review

• strength

• ROM

• posture

• joint pain/swelling/stiffness

neuromuscular system review

• CN Testing

Cognition/communication review of systems

• A/O questions

• visual/hearing deficits

• communication deficits

Tests and Measures of Impairments

• sensation

• reflexes

• strength

• range of motion

• tone/spasticity

• balance

Tests and Measures of activities

• bed mobility

• transfers

• gait

• W/C mobility

• current ADL

What should an outcome measure accomplish

appropriate level difficulty of the pt. and captures the deficit you are observing

what do outcome measures provide

standardized, objective data to show progress over time

acute examples of outcome measures

TUG, 6-minute walk test, FIST

Orthopedic examples of outcome measures

DGI, Tinetti, Berg

Examination

physical examination face-to-face with the patient to identify the subjective and objective problems/impairment/functional deficits that guide your plan of care and goals

Evaluation

explanation not face-to-face with the patient of how the impairments are causing the functional deficits and how you plan to address the problems

how to summarize the examination

• include medical diagnosis in some way

• discuss impairments found

• describe the functional limitation existing for the patient

• determine whether PT intervention will benefit the pt. and explain why

what does the assessment include

• summary of the examination

• problem list

• PT diagnosis

• establish the prognosis and rehab potential

• establish goals

prognosis

prediction of level of improvement

rehabilitation potential

likelihood of additional benefit from receiving input from rehabilitation service

factors that may influence the intervention, progress, or Outcomes

issues which complicate the overall picture of the pt.

what should goals be centered around

the patient

what are goals

• predictive portion of prognosis

• collaborative

Three Levels of Goal Writing

1. participation goals

2. activity goals

3. impairment goals

participation goals

express the expected outcomes in terms of a specific role and express the big picture

activity goals

express the expected outcomes in terms of the skills needed to participate in necessary or desired roles

impairment goals

express outcome in terms of impairments justified by relating to an activity or participation task

fundamentals of well-written goals

• goals are outcomes not processes

• goals are concrete not abstract

• goals must be measurable

• goals typically should not be intervention based

ABC of goal making

Actor, behavior, condition, degree, expected time frame

actor

who will perform the activity

behavior

description of the activity in lay language

condition

circumstance including all essential elements under which the behavior is carried out

degree

quantitative specification of performance

expected time frame

short term goals and long term goals

SMART goals ae

specific, measurable, attainable, relevant, timely

specific

clearly identify what you want the pt. to acheive

measurable

define the metric of how you are going to measure the goal

attainable

ensure the goal is challenging but doable for the patient

relevant

verify the goal is consistent with the overall goals and priorities of the patient and interdisciplinary health care team and relevant to function

timely

set a specific time frame to achieve the goal

long term goals

list of goals that reflect patient’s anticipated final status at the end of the plan of care

short term goals

serve as a bridge between current status and the long term goal

Plan of chare should include

• frequency

• duration

• services

• what intervention the pt. will participate in and why

• type of education pt. will receive

  • type of home program or instructions pt. will receive

projected discharge destination

explain why you recommend that level of care

CPT stands for what

current procedural terminology

Who determines the CPT

American Medical Association

How do CPT codes differ from ICD-10 codes

CPT codes identify services rendered rather than diagnosis

Therapeutic exercise code

97110

therapeutic activity code

97530

neuromuscular re-education code

97112

gait training code

97116

W/C management code

97542