IEP Health Related Services:
Occupational and Physical Therapy
Identifying ICD-10-CM Codes
May, 2015
What are the ICD-10-CM Codes Sets?
The ICD-10-CM code sets identify:
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Signs and symptoms
Abnormal findings
Complaints
Social circumstances
External causes of injury or diseases
Medical diagnoses
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What Does this Mean for Schools?
Schools must provide an ICD-10-CM code for
each billable IEP health related service.
These services include:
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Mental health (CTSS)
Nursing
Occupational therapy
Physical therapy
Speech-language pathology and audiology
PCA
Transportation
Assistive Technology
Interpreter Services
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Who Determines the ICD-10-CM Codes?
Diagnosis
Signs/
Symptoms
RN)
x
o
(LSN/PHN/RN, not LPN)
o
x
Occupational Therapists
o
x
Physical Therapists
o
x
Speech-Language Pathologists;
Audiology
x
x
School Psychologist
o
x
Mental Health Professionals
x
o
Provider
Primary Care (MD, PA, APRN (Advan Pract
Professional Nurses
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Who Determines the ICD-10-CM Codes
For Other IEP Health Related Services?
The IEP health related service professional who is
training, directing, supervising or ordering the service,
selects the ICD-10-CM code(s) for:
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PCA services
Special Transportation
Assistive Technology
Interpreter services
In most cases it is the same ICD-10-CM code used by
the professional.
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Student Scenario
The child has a medical diagnosis of cerebral
palsy. The IEP evaluation report indicates there is a
medical need for Occupational Therapy or Physical
Therapy and PCA services due to the lack of motor
skills, motor impairment and spasticity in arm and legs.
Occupational Therapist (OT) or Physical Therapist
(PT) services will include working with the child two
times a week for 20 minutes each time.
PCA will assist with the Activities of Daily Living (ADL)
- eating, mobility and toileting.
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Identifying the Correct ICD-10-CM Codes
Stop and think:
Am I treating the disease / disorder?
or
Am I treating a sign/symptom?
What code best describes the need for service
and the service that is being provided?
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Identify ICD-10 Code by Service Provided
The OT or PT is treating the signs, symptoms or
condition of cerebral palsy. (Lack of motor skills, motor
impairment and spasticity in arm and legs).
 The OT or PT determines the correct ICD-10-CM
code that best describes the treatment that is being
provided
 A PCA will assist the child with eating, mobility and
toileting because the same signs, symptoms or condition
that the OT or PT is treating prevents the child from
performing these tasks without assistance
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ICD-10-CM Selection
If a health care provider gives a diagnosis without
an ICD-10-CM code:
 The OT or PT contacts the primary care provider or
clinic to get the correct ICD-10-CM code OR
 The OT or PT searches for the ICD-10-CM codes, in
this scenario:
• Cerebral palsy
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Reporting ICD-10-CM Codes
 When a child has been diagnosed with a disease or
disorder from a primary care provider, report that
diagnosis code as the Primary diagnosis for all claims
for the child
 When providing health related services for a sign,
symptom, or condition resulting from the disease or
disorder, report that code as Secondary, Tertiary and so
on
 When no medical disease or disorder has been
identified, report the sign, symptom or condition code
that identifies the IEP health related service that is being
provided as the Primary diagnosis code
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Watch for ICD-10-CM Code Notations
Whether you use an online resource or purchase a ICD-10CM guide, it is important to read and understand the
guidelines and exceptions for selecting ICD-10-CM codes.
 Select codes that are valid and billable
 Watch for code notations and rules
The ICD-10-CM code must:
 Clearly represent the child’s medical need as identified
in the child’s IEP / IFSP
 Logically relate to the IEP provider/service
 Relate to the activities / tasks provided
 Be specific to the child’s needs
 Select medically necessary codes, not education codes
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Special Education Disability Categories
To qualify for Special Education a child be eligible for one of
the following Educational Disability categories:
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Speech/Language Impaired
Developmental Cognitive disability – mild to moderate
Developmental Cognitive disability – severe to profound
Physically Impaired
Visually Impaired
Specific Learning disability
Emotional/Behavioral Disorders (EDB)
Deaf-Blind
Other Health Disabilities
Autism Spectrum Disorder
Developmental Delay
Traumatic Brain Injury Disabled
Severely Multiply Impaired
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School Sources for Medical Diagnoses
 A medical diagnoses is a criteria for eligibility for these
Special Education Disability Categories: Other Health
Disabilities, Physical Impairments and Traumatic Brain
Injury.
 Speech/language pathologists and audiologists determine
the diagnoses for Speech/Language Impairments.
 Mental Health Professionals provide DSM 5 / ICD-10-CM
diagnoses when CTSS is included in the child’s IEP
needs and plan.
 Annually, medical orders are required for students
needing medication or certain treatments.
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Special Education Needs Align with ICD-10-CM
IEP Evaluation Report:
• Summarizes medical need
• States health related services are required during
school day
IEP Record: Assessment and Plan describe:
• Health problem, signs/ symptoms/ condition
• Plan of care/Treatment Plan; why and what services
are necessary, when, by whom, how often
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Documenting ICD-10-CM Codes
 Record the ICD-10-CM codes in the child’s IEP file,
not on the IEP Plan
 Follow your school district procedures to document
ICD-10-CM codes for billing purposes (some
schools will have electronic documentation
procedures)
One example is a Summary Sheet for all ICD-10-CM
codes for a child’s IEP health related services (next
slide)
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Optional Summary Sheet
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Understanding the ICD-10-CM Code
Structure
Reporting Primary and Secondary
ICD-10-CM Codes
In the Student Scenario we just looked at, the child’s
primary care provider diagnosed the child with cerebral
palsy but did not give an ICD-10-CM code.
The ICD-10-CM G80.9 has been used for other children
with this same diagnosis, but is that correct for this child?
G80.9 is an unspecified diagnosis code that does not
clearly define the issues the specific child is experiencing.
Working together the professional nurse and therapist
could search for a code that describes this child’s signs,
symptoms or conditions.
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ICD10Data.com Motor Skills, Spasticity
Reporting and Coding
For this scenario:
After reviewing the ICD-10-Codes the nurse and
therapist agree, that the ICD-10-Code G80.0 best
describes the signs, symptoms or conditions of this child.
Report the ICD-10-CM Code G80.0 for cerebral palsy
as the primary diagnosis when billing for therapy and
PCA services for this child.
Documentation should clearly define the services.
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Online Resources for ICD-10-CM
Reporting and Coding
Visit the following websites for additional guidance:
Center for Medicare & Medicaid Services (CMS) – ICD-10:
Provides history, requirements, and coding sources
Centers for Disease Control and Prevention (CDC) – ICD-10:
Provides history, requirements, and coding sources
ICD10Data.com, Example of a commercial website that can be
used to find appropriate ICD-10-CM codes
MHCP Enrolled Providers – ICD-10, Minnesota DHS webpage:
Provides periodic updates about ICD-10-CM Implementation
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ICD-10-CM Implementation Timeline
It may be necessary to work with both the ICD-9 code
315.9 and the new ICD-10-CM codes until all claims for
dates of service on or before September 30, 2015 have
been submitted.
 Use ICD-9 Code 315.9 for dates of service on or
before September 30, 2015
 Use ICD-10-CM Codes for dates of service
provided on or after October 1, 2015
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DHS – MDE Staff
Jenny Roth, DHS IEP Services Coordinator
(651) 431-2622; [email protected]
Ruth Ellen Luehr, MDE Special Education
Interagency Education Specialist
(651) 582-8403; [email protected]
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