Find comprehensive information on physical therapy diagnosis documentation, including ICD-10 codes, CPT codes, medical billing guidelines, and best practices for clinical note-taking. This resource covers common physical therapy diagnoses, evaluation procedures, treatment plans, and outcome measures, supporting accurate healthcare record keeping and optimized reimbursement for physical therapists. Learn about effective documentation strategies to improve patient care and streamline your practice workflow.
Also known as
Encounter for other specified aftercare
Aftercare following therapy, including physical therapy.
Other aftercare following surgery
Aftercare following surgery may include physical therapy.
Orthopedic aftercare
Orthopedic aftercare often involves physical therapy.
Follow this step-by-step guide to choose the correct ICD-10 code.
Is PT for a current injury/illness?
Yes
Is the diagnosis documented?
No
Is PT for aftercare?
When to use each related code
| Description |
|---|
| Physical Therapy |
| Manual Therapy |
| Therapeutic Exercise |
Using unspecified physical therapy diagnosis codes when a more specific code is available leads to inaccurate reimbursement and data.
Lack of documentation supporting the medical necessity of physical therapy services can trigger denials and compliance issues.
Applying incorrect modifiers to physical therapy CPT codes can result in claim rejection and potential overpayments or underpayments.
Patient presents for physical therapy evaluation and treatment secondary to [Specific Condition causing the need for PT, e.g., lumbar disc herniation, osteoarthritis of the knee, rotator cuff tear, cerebrovascular accident, total knee replacement]. Onset of symptoms occurred on [Date of Onset] and is characterized by [Specific symptoms, e.g., low back pain radiating to right leg, knee pain with weight-bearing, limited shoulder range of motion, left-sided weakness, post-surgical pain and stiffness]. Pain is reported as [Pain quality, e.g., sharp, dull, aching, throbbing] and [Pain intensity on a scale of 0-10]. Aggravating factors include [Activities that worsen symptoms, e.g., prolonged sitting, stair climbing, overhead reaching, transfers]. Easing factors include [Activities that lessen symptoms, e.g., rest, ice, medication, bracing]. Patient reports limitations in functional activities such as [Functional limitations, e.g., dressing, bathing, walking, lifting, working]. Past medical history includes [Relevant medical history, e.g., hypertension, diabetes, previous surgeries]. Current medications include [List of medications]. Physical examination reveals [Objective findings, e.g., decreased lumbar range of motion, positive straight leg raise test, swelling and tenderness in the knee, limited shoulder abduction and external rotation, decreased muscle strength in left extremities, surgical incision well-healed]. Diagnosis: [ICD-10 code and description, e.g., M54.5 Low back pain]. Plan of care includes [Frequency and duration of treatment, e.g., physical therapy twice a week for 6 weeks] focusing on [Treatment interventions, e.g., therapeutic exercises, manual therapy, modalities, gait training, functional activities training] to improve [Targeted outcomes, e.g., pain reduction, range of motion, strength, functional mobility, independence]. Patient education provided regarding [Patient education topics, e.g., body mechanics, home exercise program, activity modification]. Prognosis is favorable for improved function with consistent adherence to the prescribed plan of care. Follow-up scheduled for [Date of next appointment].