ICD-10-CM Reporting for IEP Heath Related Services ...

[Pages:3]ICD-10-CM Reporting for IEP Heath Related Services Treating the Signs, Symptom or Condition

IEP SECTIONS IEP Team Evaluation Report

IEP Plan The Physical Therapist (PT) is the health related service professional. The PT should determine the most appropriate ICD-10-CM code

IEP DETAILS Through direct observation, discussions, and review of the evaluations done by the IEP health related service professionals, the IEP team determines the child has a disability that would interfere with the child being able to attend school and receive a Free Appropriate Public Education. The child has difficulty walking, has an uneven gait, frequently falls and struggles transitioning from a seated position to standing. 1. A PT will work with the child for 30 minutes each twice a week .A walker will

be purchased for the child for balance and mobility to be used at home and at school. 2. Special transportation to and from school each day. The child will need assistance getting on and off the bus, assistance getting the walker on and off the bus. 3. A PCA will assist the child for toileting and getting lunch.

NOTE: In this example the professional selected ICD-10-CM code R26.1 For billing purposes in this example the ICD-10- code R26.1 can be used for all services identified in the IEP Plan. Because of the Paralytic gait condition:

The child's medical needs indicate the child needs physical therapy is to improve their gait. The child needs a walker to stabilize this gait and balance. The child is not able to balance a lunch tray and walk.

The child needs help when toileting to get on and off the toilet and back to their walke

ICD-10-CM Reporting for IEP Heath Related Services Treating the Disease or Disorder and a Sign, Symptom or Condition

IEP SECTIONS IEP Team Evaluation Report

IEP DETAILS Through direct observation, discussions, and review of the evaluations done by the IEP health related service professionals, the IEP team determines the child has a disability that would interfere with the child being able to attend school and receive a Free Appropriate Public Education.

The mental health professional has diagnosed the child as having autism. The child will not make eye contact or look toward a person when in a conversation, will not track with the conversation. The child also mumbles and repeats words more that forming sentences

The IEP team determines the child has a mixed receptive-expressive language speech as one of the conditions of autism.

IEP Plan Sign, symptom, or condition The mental health professional diagnosed this child as having Autism (F84.0). Autism diagnosis does not define treatment. (Primary Diagnosis)

The primary care provider has diagnosed the child as having asthma and needs medication and nebulizer treatments 1. A SLP will see this child 1.1 for twenty minutes twice a week 2. A SLP will work with the child once a week for 30 minutes in a 3.1 group

setting

The Speech Language Pathologist (SLP) is the health related service professional for the speech disorder and should determine the most appropriate ICD10-CM code for that condition they will be treating. For this example the professional selected F80.2 (Secondary Diagnosis) Medical Diagnosis Doctors Order were provided for the treatment of Asthma (J42.21) The services provided by the Nurse will be billed using the ICD-10-CM code for Asthma. The nurse is treating the asthma. The code supplied by the primary doctor

School nurse will administer medication and nebulizer treatment per doctor's orders

NOTE: For billing purposes in this example the ICD-10-CM code (F84.0) identifying autism would be the primary diagnosis, and the ICD-10-CM code F80.2 for the mixed receptivie language disorder identifies the sign , symptom or condition of autism and is the secondary diagnosis.

The ICD-10-CM code J42. 21 identifies asthma, the disease or disorder that is being treated by the nurse when administering the medication and nebulizer treatments.

TPR Forum 4-22-15

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