What is the difference between a medical diagnosis and a treatment diagnosis? How do we select the correct medical diagnosis on therapy evaluations? These are questions that therapists ask all the time. Why do therapists struggle in this area? Because therapists are not coders. Therapists receive little to no training in school and in clinical affiliations. So why is everyone concerned about therapy coding? The answer is plainly simple! Skilled nursing facilities are under extreme scrutiny. Defending against technical denials, which occur at the time of claim submission, due to coding edits is imperative to avoid the extensive time and resources and possible revenue cycle implications of the appeals process.
Let’s look at the difference between medical and treatment diagnoses.
| Medical Diagnoses | Treatment Diagnoses |
| Part A: Admitting diagnosis to the hospital and the reason for the admission to the SNF. Usually assigned by the facility prior to/upon admission to the facility | Determined by the evaluating therapist based off evaluation/assessment |
| Part A: All disciplines use the facility selected primary medical diagnostic code(s) that will be used to bill Medicare for the SNF services | Should clearly relate to the identified functional limitations the resident is presenting with that was identified during the evaluation process |
| Is the medical condition (disease or condition) that has caused the impairment in function (signs and symptoms) | Best presents the signs, symptoms, condition, and/or co-morbidities therapy will be treating |
| Part B: Event causing diagnosis- the diagnosis representing the change in condition that warranted a referral to rehab services. Therapist selected primary medical code(s) which is linked to the need for the skilled services. May vary from one discipline to another | Often, there will be more than one treatment diagnosis since more than one underlying impairment and/or functional deficit is being treated |
| Important to add any other pertinent medical ICD-10 codes which directly relate to the therapy. These reflect the medical complexity | Include all treatment diagnoses that reflect the signs and symptoms and resulting impairment that therapy will be working to improve |
Physical and occupational therapists often use the underlying impairment of muscle weakness for a treatment diagnosis because muscle weakness causes many functional deficits and impacts every aspect of the physical and occupational therapy plan of treatment. Even though muscle weakness is a major player, it’s not alone. Therapists treat a multiple of underlying impairments and functional deficits such as lack of coordination, difficulty walking, joint stiffness, low back pain, spasm of muscle, contracture, neuralgia, laxity of ligament, pain in limb, kyphosis, abnormality of gait, facial weakness, edema, vertigo, dysphagia, pressure ulcer, and aphonia to name a few.
Therapists will need to enhance their knowledge of the treatment diagnoses that are available to them under ICD-10 and realize there is not one secret code to use. On the contrary, there are multiple.
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