History

• 45-year-old male 3 days after onset of acute low back pain (LBP) with (L) LE pain into posterior thigh to knee.
• Patient was seen by an orthopaedist and referred to physical therapy.
• Imaging revealed no fracture to the lumbar spine.
• Second episode of this condition in the past 6 months. Previous episode had no LE symptoms.
• Has been on bed rest since onset.

Exam

• Patient reports that on 0-10 scale pain is 5/10 at best and 8/10 at worst.
• Patient has problems with muscle and joint functions.
• Patient is unable to walk community distances due to pain.
• Oswestry Disability Index Score: 36%, which represents moderate disability.

Assessment and Plan

• Patient presents with body function impairments of back muscle and joints that prevent participation in activities related to mobility, work, and recreation, due to an acute exacerbation of recurring low back pain and associated (referred) lower extremity pain.
• Perform physical therapy 3 times/week for 2 weeks.
• Progress interventions that include: manual therapy; trunk coordination, strengthening, and endurance exercises; patient education; and progressive exercise and fitness activities.

Summary of ICD-10-CM Impacts for PT Practice

Clinical Documentation

1. Describe the current signs and symptoms that the physical therapist will address.
2. Document that there is no definitive imaging or test that identifies the cause of the low back pain as sciatica.
3. Document that the primary reason physical therapy is involved is to resolve the pain and improve mobility.

*To avoid payment delays or denials, check with each payer to determine the appropriate first-listed diagnosis.

Review other case studies and ICD-10 resources.*To avoid payment delays or denials, check with each payer to determine the appropriate first-listed diagnosis.