Physical Medicine and Rehab

Physical Medicine and Rehab

General Documentation Considerations

• Specify rehabilitation services related to an injury by the appropriate episode of care:
  
  • Initial:  Used while the patient is receiving active treatment (new condition develops while in the rehabilitation setting)
  • Subsequent:  Used after the patient has received active and is receiving routine care for the condition during the healing process (routine, delayed or with nonunion) or recovery phase
  • Sequela:  Used for complications or conditions arising as a direct result of the condition
  • Chronic conditions may be the reason for admission to the rehabilitation facility
    • If the patient leaves the rehabilitation facility and returns to resume treatment, the original chronic condition remains the first listed diagnosis even if treatment is continued for the condition the patient was originally admitted for at the acute care facility
• Rehabilitation services for the treatment of sequela of non-traumatic infarctions, hemorrhages, etc.
  • Specify the site of the infarction or bleed
  • Identify the associated symptom requiring therapy services: 
    • Example:  Aphasia following cerebral infarction
  • Types of paresis/paralysis should be identified, including laterality, and indicate whether it is a nondominate or dominate side
    • Example:  Monoplegia of left leg nondominate following subarachnoid hemorrhage
• For injuries such as a fracture, the admission to rehab is identified as a subsequent visit
• Fractures should contain documentation regarding laterality, open/closed, displaced/nondisplaced
• Open fractures based on the Gustilo classification of Type I or II and/or Type IIIA, IIIB or IIIC
• Indicate the healing status (e.g., routine healing, delayed healing, nonunion, malunion)

Diagnoses

ICD-9 to ICD-10 Crosswalk

The codes in these crosswalks were selected based on the most commonly used ICD-9 codes according to historical MedStar Health coding data and from professional coding associations, and are ordered by frequency of use. 

Not all the codes you need are contained in this list. For a comprehensive list of ICD-10 codes, use Diagnosis Assistant or the IMO Anywhere tool.

Code	Description (ICD-9 codes are in blue)
905.1	Late effect of fracture of spine and trunk without spinal cord lesion
	Document level of injury at vertebral level and the type of fracture with underlying disease process if applicable, (i.e. collapsed vertebra, age related osteoporosis with pathologic fracture, wedge compression fracture, stable or unstable burst fracture) Below are examples of diagnosis choices for T4 level:
M48.54XS	Collapsed vertebra, not elsewhere classified, thoracic region
M80.08XS	Age-related osteoporosis with current pathological fracture, vertebra(e), sequela
S22.040S	Wedge compression fracture of fourth thoracic vertebra, sequela
S22.041S	Stable burst fracture of fourth thoracic vertebra, sequela
S22.042S	Unstable burst fracture of fourth thoracic vertebra, sequela
S22.048S	Other fracture of fourth thoracic vertebra, sequela
907.2	Late effect of spinal cord injury
	ICD-10 allows for detailed description of cord lesions and syndromes at each vertebral level of the cervical and lumbar spine. Note if injury resulted in a complete lesion, central cord syndrome, anterior cord syndrome, Brown-Sequard syndrome, or other type of incomplete lesion at the specific vertebral level. Below are code examples for the C3 level:
S14.113S	Complete lesion at C3 level of cervical spinal cord, sequela
S14.123S	Central cord syndrome at C3 level of cervical spinal cord, sequela
S14.133S	Anterior cord syndrome at C3 level of cervical spinal cord, sequela
S14.143S	Brown-Séquard syndrome at C3 level of cervical spinal cord, sequela
S14.153S	Other incomplete lesion at C3 level of cervical spinal cord, sequela
	If disability is a result of spinal cord concussion and edema, document if the injury is at the cervical, thoracic, lumbar, or sacral level.
S14.0XXS	Concussion and edema of cervical spinal cord, sequela
S24.0XXS	Concussion and edema of thoracic spinal cord, sequela
S44.01XS	Concussion and edema of lumbar spinal cord, sequela
S34.02XS	Concussion and edema of sacral spinal cord, sequela
907.2	Late effect of spinal cord injury
	ICD-10 allows for detailed description of cord lesions and syndromes at each vertebral level of the cervical and lumbar spine. Note if injury resulted in a complete lesion, central cord syndrome, anterior cord syndrome, Brown-Sequard syndrome, or other type of incomplete lesion at the specific vertebral level. Below are code examples for the C3 level:
S14.113S	Complete lesion at C3 level of cervical spinal cord, sequela
S14.123S	Central cord syndrome at C3 level of cervical spinal cord, sequela
S14.133S	Anterior cord syndrome at C3 level of cervical spinal cord, sequela
S14.143S	Brown-Séquard syndrome at C3 level of cervical spinal cord, sequela
S14.153S	Other incomplete lesion at C3 level of cervical spinal cord, sequela
	If disability is a result of spinal cord concussion and edema, document if the injury is at the cervical, thoracic, lumbar, or sacral level.
S14.0XXS	Concussion and edema of cervical spinal cord, sequela
S24.0XXS	Concussion and edema of thoracic spinal cord, sequela
S44.01XS	Concussion and edema of lumbar spinal cord, sequela
S34.02XS	Concussion and edema of sacral spinal cord, sequela
851.44	Cerebellar or brain stem contusion without open intracranial wound with prolonged (more than 24 hours) loss consciousness and return to pre-existing conscious level
S06.375A	Contusion, laceration, and hemorrhage of cerebellum with loss of consciousness greater than 24 hours with return to pre-existing conscious level, initial encounter
S06.385A	Contusion, laceration, and hemorrhage of brainstem with loss of consciousness greater than 24 hours with return to pre-existing conscious level, initial encounter
808.43	Multiple closed pelvic fractures with disruption of pelvic circle
S32.810A	Multiple fractures of pelvis with stable disruption of pelvic ring, initial encounter for closed fracture
S32.811A	Multiple fractures of pelvis with unstable disruption of pelvic ring, initial encounter for closed fracture
432.1	Subdural hemorrhage
I62.01	Nontraumatic acute subdural hemorrhage
I62.02	Nontraumatic sub acute subdural hemorrhage
I62.03	Nontraumatic chronic subdural hemorrhage
434.91	Cerebral artery occlusion unspecified with cerebral infarction
I63.511	Cerebral infarction due to unspecified occlusion or stenosis of right middle cerebral artery
I63.512	Cerebral infarction due to unspecified occlusion or stenosis of left middle cerebral artery
I63.521	Cerebral infarction due to unspecified occlusion or stenosis of right anterior cerebral artery
I63.522	Cerebral infarction due to unspecified occlusion or stenosis of left anterior cerebral artery
I63.531	Cerebral infarction due to unspecified occlusion or stenosis of right posterior cerebral artery
I63.532	Cerebral infarction due to unspecified occlusion or stenosis of left posterior cerebral artery
808.0	Closed fracture of acetabulum
	Laterality must be included in the diagnosis selection. Multiple documentation requirements for noting location/up of fracture. These include; (displaced or non-displaced, , anterior or posterior column, transverse or transverse posterior, or radial wall or dome). Code examples include:
S32.411A	Displaced fracture of anterior wall of right acetabulum, initial
S32.424A	Nondisplaced fracture of posterior wall of right acetabulum, initial
S32.432A	Displaced fracture of anterior column [iliopubic] of left acetabulum, initial encounter for closed fracture
S32.443A	Displaced fracture of posterior column [ilioischial] of unspecified acetabulum, initial encounter for closed fracture
S32.482A	Displaced dome fracture of left acetabulum, initial encounter for closed fracture
433.21	Occlusion and stenosis of vertebral artery with cerebral infarction
	Note if infarction is caused by thrombosis or embolism. Include laterality of vertebral artery in diagnosis selection or indicate it is unspecified. Examples:
I63.011	Cerebral infarction due to thrombosis of right vertebral artery
I63.012	Cerebral infarction due to thrombosis of left vertebral artery
I63.111	Cerebral infarction due to embolism of right vertebral artery
I63.112	Cerebral infarction due to embolism of left vertebral artery
I63.019	Cerebral infarction due to thrombosis of unspecified vertebral artery
I63.119	Cerebral infarction due to embolism of unspecified vertebral artery
433.11	Occlusion and stenosis of carotid artery with cerebral infarction
	Note if infarction is caused by thrombosis or embolism. Include laterality in diagnosis selection or indicate it is unspecified. Examples:
I63.031	Cerebral infarction due to thrombosis of right carotid artery
I63.032	Cerebral infarction due to thrombosis of left carotid artery
I63.131	Cerebral infarction due to embolism of right carotid artery
I63.132	Cerebral infarction due to embolism of left carotid artery
I63.231	Cerebral infarction due to unspecified occlusion or stenosis of right carotid arteries
I63.232	Cerebral infarction due to unspecified occlusion or stenosis of left carotid arteries
I63.039	Cerebral infarction due to thrombosis of unspecified carotid artery
433.01	Occlusion and stenosis of basilar artery with cerebral infarction
I63.02	Cerebral infarction due to thrombosis of basilar artery
I63.12	Cerebral infarction due to embolism of basilar artery
432.1	Subdural hemorrhage
I62.01	Nontraumatic acute subdural hemorrhage
I62.02	Nontraumatic sub acute subdural hemorrhage
I62.03	Nontraumatic chronic subdural hemorrhage
808.43	Multiple closed pelvic fractures with disruption of pelvic circle
S32.810A	Multiple fractures of pelvis with stable disruption of pelvic ring, initial encounter for closed fracture
S32.811A	Multiple fractures of pelvis with unstable disruption of pelvic ring, initial encounter for closed fracture
344.1	Paraplegia
G04.1	Tropical spastic paraplegia
G82.21	Paraplegia, complete
G82.22	Paraplegia, incomplete
780.72	Functional quadriplegia
R53.2	Functional quadriplegia
852.45	Extradural hemorrhage following injury without open intracranial wound with prolonged (more than 24 hours) loss of consciousness without return to pre-existing conscious level
S06.4X6A	Epidural hemorrhage with loss of consciousness greater than 24 hours without return to pre-existing conscious level with patient surviving, initial encounter
433.31	Occlusion and stenosis of multiple and bilateral precerebral arteries with cerebral infarction
I63.59	Cerebral infarction due to unspecified occlusion or stenosis of other cerebral artery
344.03	Quadriplegia c5-c7 complete
G82.53	Quadriplegia, C5-C7 complete
344.01	Quadriplegia c1-c4 complete
G82.51	Quadriplegia, C1-C4 complete
344.02	Quadriplegia c1-c4 incomplete
G82.52	Quadriplegia, C1-C4 incomplete
344.04	Quadriplegia c5-c7 incomplete
G82.54	Quadriplegia, C5-C7 incomplete