For Dates of Service Before November 1, 2013

Allowable ICD-9-CM Codes for Physical Therapy Spell of Illness Approval (Organized by Statements)

PT providers should use the following chart to determine the allowable combinations of ICD-9-CM codes and statements for SOI approval. Only one of statements "A" through "F" from the PA/SOIA must be true for SOI approval. The combination of the true statement and the primary ICD-9-CM diagnosis code or the ICD-9-CM surgical procedure code is then used by ForwardHealth to assign the maximum allowable treatment days for the SOI. Statement "G" must also be true for SOI approval, but it is not used to determine the maximum allowable treatment days.

The statements below are from Element 11 of the PA/SOIA:

The member experienced the onset of a new neuromuscular disease, injury, or condition six weeks ago or less.
The member experienced the onset of a new musculoskeletal disease, injury, or condition six weeks ago or less.
The member experienced the onset of a new problem or complication associated with physiologic disease, injury, or condition six weeks ago or less.
The member experienced the onset of a new psychological disease, injury, or condition six weeks ago or less.
The member experienced an exacerbation of a pre-existing condition six weeks ago or less.
The member experienced a regression of his or her condition due to lack of therapy six weeks ago or less.

AND

There is a reasonable expectation that the member will return to his or her previous level of function by the end of this SOI or sooner.

Note: Statement "D" does not apply to PT services.

Each chart is specific to one of the above statements. The statement and the maximum allowable treatment days are provided at the top of each chart.

The following instructions describe how to use these charts:

Find the chart that corresponds to the true statement (Element 11 of the PA/SOIA).
Find the appropriate ICD-9-CM code and description. The diagnosis codes are listed before the surgical procedure codes. The code descriptions are organized alphabetically within these categories (Element 10 of the PA/SOIA).
If the ICD-9-CM code is listed in the chart, refer to the statement at the top of the chart for the maximum allowable treatment days for the corresponding combination of the ICD-9-CM code and statement.
If the ICD-9-CM code is not listed in the chart, the combination of the code and statement does not allow for SOI approval. The ICD-9-CM code may be listed under another statement.

Some ICD-9-CM codes have more than one allowable statement for SOI approval. PT providers should determine which statement best describes the member's condition.

Only the ICD-9-CM codes listed in the following charts are available for SOI approval. If the ICD-9-CM code for the PT service is not listed, the provider should submit the PA/RF and the PA/TA.

Primary ICD-9-CM Diagnosis Code Description	Primary ICD-9-CM Diagnosis Code
Statement A - The member experienced the onset of a new neuromuscular disease, injury, or condition six weeks ago or less. Providers will be allowed 19 days for an SOI with one of the following ICD-9-CM codes.
Acute infective polyneuritis (Guillain-Barre syndrome; postinfectious polyneuritis)	357.0
Acute, but ill-defined, cerebrovascular disease (incl., CVA)	436
Anoxic brain damage	348.1
Bacterial meningitis	320.0-320.9
Brachial neuritis or radiculitis NOS	723.4
Cauda equina syndrome	344.6
Cerebral embolism	434.10-434.11
Cerebral laceration and contusion	851.0-851.99
Cerebral thrombosis	434.00-434.01
Cervicalgia	723.1
Cervicobrachial syndrome (diffuse)	723.3
Diabetes mellitus	250.0-250.93
Disorders of other cranial nerves	352.0-352.9
Encephalitis, myelitis, and encephalomyelitis	323.0-323.9
Encephalopathy, unspecified	348.3
Facial nerve disorders (incl., Bell's palsy)	351.0-351.9
Head injury, unspecified	959.01
Hemplegia and hemiparesis	342.0-342.92
Huntington's chorea	333.4
Intracerebral hemorrhage	431
Intracranial injury of other and unspecified nature	854.0-854.19
Late effects of acute poliomyelitis	138
Malignant neoplasm of brain	191.0-191.9
Malignant neoplasm of head, face, and neck	195.0
Meningitis due to other organisms	321.0-321.8
Meningitis of unspecified cause	322.0-322.9
Mononeuritis of lower limb and unspecified site	355.0-355.9
Mononeuritis of upper limb and mononeuritis multiplex (incl., Carpal tunnel syndrome)	354.0-354.9
Motor neuron disease (incl., Amyotrophic lateral sclerosis)	335.20-335.29
Multiple sclerosis	340
Myasthenia gravis	358.0
Nerve root and plexus disorders	353.0-353.9
Nontraumatic extradural hemorrhage	432.0
Other and unspecified intracranial hemorrhage following injury	853.0-853.19
Other choreas	333.5
Parkinson's disease	332.0-332.1
Peroneal muscular atrophy (Charcot-Marie-Tooth disease)	356.1
Secondary malignant neoplasm of brain and spinal cord	198.3
Secondary malignant neoplasm of other parts of nervous system	198.4
Spinocerebellar disease (ataxias)	334.0-334.9
Subarachnoid hemorrhage	430
Subarachnoid, subdural, and extradural hemorrhage, following injury	852.0-852.59
Subdural hemorrhage	432.1
Toxic encephalopathy	349.82
Trigeminal nerve disorders (incl., Trigeminal neuralgia)	350.1-350.9
ICD-9-CM Surgical Procedure Code Description	ICD-9-CM Surgical Procedure Code
Extracranial ventricular shunt	02.31-02.39
Incision of cerebral meninges	01.31
Other craniectomy	01.25
Other craniotomy	01.24
Repair of cerebral meninges	02.11-02.14
Revision, removal, and irrigation of ventricular shunt	02.41-02.43

Primary ICD-9-CM Diagnosis Code Description	Primary ICD-9-CM Diagnosis Code
Statement B - The member experienced the onset of a new musculoskeletal disease, injury, or condition six weeks ago or less. Providers will be allowed 11 days for an SOI with one of the following ICD-9-CM codes.
Ankylosing spondylitis and other inflammatory spondylopathies	720.0-720.9
Complications due to internal joint prosthesis	996.77
Complications due to other internal orthopedic device, implant, and graft	996.78
Complications of reattached extremity or body part	996.91-996.99
Fracture of lower limb	820-829.1
Fracture of pelvis	808.0-808.9
Fracture of upper limb	810-819.1
Gouty arthropathy	274.0
Infection and inflammatory reaction due to internal joint prosthesis	996.66
Infection and inflammatory reaction due to other internal orthopedic device, implant, and graft	996.67
Internal derangement of knee (incl., Meniscal tears and chondromalacia of patella)	717.0-717.7
Intervertebral disc disorders	722.0-722.93
Juvenile chronic polyarthritis	714.30-714.33
Kyphoscoliosis and scoliosis	737.30-737.39
Mechanical complication of internal orthopedic device, implant, and graft	996.4
Osteoarthosis and allied disorders	715.0-715.9
Other disorders of synovium, tendon, and bursa (incl., synovitis and tenosynovitis)	727.0-727.09
Other unspecified disorders of back (incl., Lumbago, sciatica, backache)	724.0-724.9
Pathologic fracture	733.10-733.19
Pathological dislocation of joint	718.2
Peripheral enthesopathies and allied syndromes (incl., adhesive capsulitis of shoulder, rotator cuff syndrome, epicondylitis, bursitis, tendinitis)	726.0-726.9
Rheumatoid arthritis	714.0
Spasmodic torticollis	333.83
Sprains and strains of joints and adjacent muscles	840-848.9
Temporomandibular joint disorders	524.60-524.69
Torticollis, unspecified	723.5
Traumatic amputation of arm and hand (complete) (partial)	887.0-887.7
Traumatic amputation of foot (complete) (partial)	896.0-896.3
Traumatic amputation of leg(s) (complete) (partial)	897.0-897.7
Traumatic amputation of other finger(s) (complete) (partial)	886.0-886.1
Traumatic amputation of thumb (complete) (partial)	885.0-885.1
Traumatic amputation of toe(s) (complete) (partial)	895.0-895.1
ICD-9-CM Surgical Procedure Code Description	ICD-9-CM Surgical Procedure Code
Amputation of lower limb	84.10-84.19
Amputation of upper limb	84.00-84.09
Arthroplasty and repair of hand, fingers, and wrist	81.71-81.79
Arthroplasty and repair of shoulder and elbow	81.80-81.85
Excision of intervertebral disc	80.51
Excision or destruction of intervertebral disc, unspecified	80.50
Five-in-one repair of knee	81.42
Intervertebral chemonucleolysis	80.52
Joint replacement of lower extremity	81.51-81.59
Mastectomy	85.41-85.48
Rotator cuff repair	83.63
Spinal fusion	81.00-81.08
Triad knee repair	81.43

Primary ICD-9-CM Diagnosis Code Description	Primary ICD-9-CM Diagnosis Code
Statement C - The member experienced the onset of a new problem or complication associated with physiologic disease, injury, or condition six weeks ago or less. Providers will be allowed 15 days for an SOI with one of the following ICD-9-CM codes.
Abdominal aneurysm, ruptured	441.3
Aortic aneurysm of unspecified site, ruptured	441.5
Arterial embolism and thrombosis of abdominal aorta	444.0
Arterial embolism and thrombosis of thoracic aorta	444.1
Benign paroxysmal positional vertigo	386.11
Complications of transplanted organ	996.80-996.89
Decubitis ulcer	707.0
Dissection of aorta	441.00-441.03
Epilepsy	345.0-345.91
Gangrene	785.4
Gas gangrene	040.0
Headache	784.0
Human immunodeficiency virus (HIV) infection	042
Meniere's disease	386.0
Migraine	346.0-346.9
Orthostatic hypotension	458.0
Other lymphedema	457.1
Postmastectomy lymphedema syndrome	457.0
Raynaud's syndrome	443.0
Reflex sympathetic dystrophy	337.20-337.29
Sickle-cell anemia	282.60-282.69
Systemic lupus erythematosus	710.0
Systemic sclerosis	710.1
Thoracic aneurysm, ruptured	441.1
Thoracoabdominal aneurysm, ruptured	441.6
Ulcer of lower limbs, except decubitus ulcer	707.10-707.9

Statement D - The member experienced the onset of a new psychological disease, injury, or condition six weeks ago or less.

This statement does not apply to PT services.

Primary ICD-9-CM Diagnosis Code Description	Primary ICD-9-CM Diagnosis Code
Statement E - The member experienced an exacerbation of a pre-existing condition six weeks ago or less. Providers will be allowed 16 days for an SOI with one of the following ICD-9-CM codes.
Acute infective polyneuritis (Guillain-Barre syndrome; postinfectious polyneuritis)	357.0
Acute, but ill-defined, cerebrovascular disease (incl., CVA)	436
Anoxic brain damage	348.1
Cerebral embolism	434.10-434.11
Cerebral laceration and contusion	851.0-851.99
Cerebral thrombosis	434.00-434.01
Encephalopathy, unspecified	348.3
Head injury, unspecified	959.01
Hemplegia and hemiparesis	342.0-342.92
Human immunodeficiency virus (HIV) infection	042
Huntington's chorea	333.4
Intracerebral hemorrhage	431
Intracranial injury of other and unspecified nature	854.0-854.19
Juvenile chronic polyarthritis	714.30-714.33
Late effects of cerebrovascular disease	438.0-438.9
Motor neuron disease (incl., Amyotrophic lateral sclerosis)	335.20-335.29
Multiple sclerosis	340
Myasthenia gravis	358.0
Nontraumatic extradural hemorrhage	432.0
Other and unspecified intracranial hemorrhage following injury	853.0-853.19
Other choreas	333.5
Other lymphedema	457.1
Parkinson's disease	332.0-332.1
Postmastectomy lymphedema syndrome	457.0
Rheumatoid arthritis	714.0
Sickle-cell anemia	282.60-282.69
Spinocerebellar disease (ataxias)	334.0-334.9
Subarachnoid hemorrhage	430
Subarachnoid, subdural, and extradural hemorrhage, following injury	852.0-852.59
Subdural hemorrhage	432.1
Toxic encephalopathy	349.82
ICD-9-CM Surgical Procedure Code Description	ICD-9-CM Surgical Procedure Code
Extracranial ventricular shunt	02.31-02.39
Incision of cerebral meninges	01.31
Other craniectomy	01.25
Other craniotomy	01.24
Repair of cerebral meninges	02.11-02.14
Revision, removal, and irrigation of ventricular shunt	02.41-02.43

Primary ICD-9-CM Diagnosis Code Description	Primary ICD-9-CM Diagnosis Code
Statement F - The member experienced a regression of his or her condition due to lack of therapy six weeks ago or less. Providers will be allowed 17 days for an SOI with one of the following ICD-9-CM codes.
Anoxic brain damage	348.1
Contracture of joint	718.4
Encephalopathy, unspecified	348.3
Toxic encephalopathy	349.82