For Dates of Service Before November 1, 2013

Allowable ICD-9-CM Codes for Physical Therapy (Organized by Codes)

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:

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

    7. AND

  7. 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.

Columns "A" through "F" in the following chart correspond to statements "A" through "F" from Element 11 of the PA/SOIA. The number of days that follow each letter represent the maximum allowable treatment days that correspond with the condition identified in that statement.

The following instructions describe how to use this chart:

  1. 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).
  2. Follow the row across to determine which statement(s) corresponds with the ICD-9-CM code (Element 11 of the PA/SOIA).
  3. Follow the appropriate column(s) up to determine the maximum allowable treatment days for the corresponding combination of the ICD-9-CM code and 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 chart are available for SOI approval. If the ICD-9-CM code for the PT service is not listed, the provider should submit PA/RF and the PA/TA.

Primary ICD-9-CM Diagnosis Code Description

Primary ICD-9-CM Diagnosis Code

A 19 Days

B 11 Days

C 15 Days

D N/A*

E 16 Days

F 17 Days

Abdominal aneurysm, ruptured

441.3

    

X

      

Acute infective polyneuritis (Guillain-Barre syndrome; postinfectious polyneuritis)

357.0

X

      

X

  

Acute, but ill-defined, cerebrovascular disease (incl., CVA)

436

X

      

X

  

Ankylosing spondylitis and other inflammatory spondylopathies

720.0-720.9

  

X

        

Anoxic brain damage

348.1

X

      

X

X

Aortic aneurysm of unspecified site, ruptured

441.5

    

X

      

Arterial embolism and thrombosis of abdominal aorta

444.0

    

X

      

Arterial embolism and thrombosis of thoracic aorta

444.1

    

X

      

Bacterial meningitis

320.0-320.9

X

          

Benign paroxysmal positional vertigo

386.11

    

X

      

Brachial neuritis or radiculitis NOS

723.4

X

          

Cauda equina syndrome

344.6

X

          

Cerebral embolism

434.10-434.11

X

      

X

  

Cerebral laceration and contusion

851.0-851.99

X

      

X

  

Cerebral thrombosis

434.00-434.01

X

      

X

  

Cervicalgia

723.1

X

          

Cervicobrachial syndrome (diffuse)

723.3

X

          

Complications due to internal joint prosthesis

996.77

  

X

        

Complications due to other internal orthopedic device, implant, and graft

996.78

  

X

        

Complications of reattached extremity or body part

996.91-996.99

  

X

        

Complications of transplanted organ

996.80-996.89

    

X

      

Contracture of joint

718.4

          

X

Decubitis ulcer

707.0

    

X

      

Diabetes mellitus

250.0-250.93

X

          

Disorders of other cranial nerves

352.0-352.9

X

          

Dissection of aorta

441.00-441.03

    

X

      

Encephalitis, myelitis, and encephalomyelitis

323.0-323.9

X

          

Encephalopathy, unspecified

348.3

X

      

X

X

Epilepsy

345.0-345.91

    

X

      

Facial nerve disorders (incl., Bell's palsy)

351.0-351.9

X

          

Fracture of lower limb

820-829.1

  

X

        

Fracture of pelvis

808.0-808.9

  

X

        

Fracture of upper limb

810-819.1

  

X

        

Gangrene

785.4

    

X

      

Gas gangrene

040.0

    

X

      

Gouty arthropathy

274.0

  

X

        

Head injury, unspecified

959.01

X

      

X

  

Headache

784.0

    

X

      

Hemplegia and hemiparesis

342.0-342.92

X

      

X

  

Human immunodeficiency virus (HIV) infection

042

    

X

  

X

  

Huntington's chorea

333.4

X

      

X

  

Infection and inflammatory reaction due to internal joint prosthesis

996.66

  

X

        

Infection and inflammatory reaction due to other internal orthopedic device, implant, and graft

996.67

  

X

        

Internal derangement of knee (incl., Meniscal tears and chondromalacia of patella)

717.0-717.7

  

X

        

Intervertebral disc disorders

722.0-722.93

  

X

        

Intracerebral hemorrhage

431

X

      

X

  

Intracranial injury of other and unspecified nature

854.0-854.19

X

      

X

  

Juvenile chronic polyarthritis

714.30-714.33

  

X

    

X

  

Kyphoscoliosis and scoliosis

737.30-737.39

  

X

        

Late effects of acute poliomyelitis

138

X

          

Late effects of cerebrovascular disease

438.0-438.9

        

X

  

Malignant neoplasm of brain

191.0-191.9

X

          

Malignant neoplasm of head, face, and neck

195.0

X

          

Mechanical complication of internal orthopedic device, implant, and graft

996.4

  

X

        

Meniere's disease

386.0

    

X

      

Meningitis due to other organisms

321.0-321.8

X

          

Meningitis of unspecified cause

322.0-322.9

X

          

Migraine

346.0-346.9

    

X

      

Mononeuritis of lower limb and unspecified site

355.0-355.9

X

          

Mononeuritis of upper limb and mononeuritis multiplex (incl., Carpal tunnel syndrome)

354.0-354.9

X

          

Motor neuron disease (incl., Amyotrophic lateral sclerosis)

335.20-335.29

X

      

X

  

Multiple sclerosis

340

X

      

X

  

Myasthenia gravis

358.0

X

      

X

  

Nerve root and plexus disorders

353.0-353.9

X

          

Nontraumatic extradural hemorrhage

432.0

X

      

X

  

Orthostatic hypotension

458.0

    

X

      

Osteoarthosis and allied disorders

715.0-715.9

  

X

        

Other and unspecified intracranial hemorrhage following injury

853.0-853.19

X

      

X

  

Other choreas

333.5

X

      

X

  

Other disorders of synovium, tendon, and bursa (incl., synovitis and tenosynovitis)

727.0-727.09

  

X

        

Other lymphedema

457.1

    

X

  

X

  

Other unspecified disorders of back (incl., Lumbago, sciatica, backache)

724.0-724.9

  

X

        

Parkinson's disease

332.0-332.1

X

      

X

  

Pathologic fracture

733.10-733.19

  

X

        

Pathological dislocation of joint

718.2

  

X

        

Peripheral enthesopathies and allied syndromes (incl., adhesive capsulitis of shoulder, rotator cuff syndrome, epicondylitis, bursitis, tendinitis)

726.0-726.9

  

X

        

Peroneal muscular atrophy (Charcot-Marie-Tooth disease)

356.1

X

          

Postmastectomy lymphedema syndrome

457.0

    

X

  

X

  

Raynaud's syndrome

443.0

    

X

      

Reflex sympathetic dystrophy

337.20-337.29

    

X

      

Rheumatoid arthritis

714.0

  

X

    

X

  

Secondary malignant neoplasm of brain and spinal cord

198.3

X

          

Secondary malignant neoplasm of other parts of nervous system

198.4

X

          

Sickle-cell anemia

282.60-282.69

    

X

  

X

  

Spasmodic torticollis

333.83

  

X

        

Spinocerebellar disease (ataxias)

334.0-334.9

X

      

X

  

Spondylosis and allied disorders

721.0-721.9

  

X

        

Sprains and strains of joints and adjacent muscles

840-848.9

  

X

        

Subarachnoid hemorrhage

430

X

      

X

  

Subarachnoid, subdural, and extradural hemorrhage, following injury

852.0-852.59

X

      

X

  

Subdural hemorrhage

432.1

X

      

X

  

Systemic lupus erythematosus

710.0

    

X

      

Systemic sclerosis

710.1

    

X

      

Temporomandibular joint disorders

524.60-524.69

  

X

        

Thoracic aneurysm, ruptured

441.1

    

X

      

Thoracoabdominal aneurysm, ruptured

441.6

    

X

      

Torticollis, unspecified

723.5

  

X

        

Toxic encephalopathy

349.82

X

      

X

X

Traumatic amputation of arm and hand (complete) (partial)

887.0-887.7

  

X

        

Traumatic amputation of foot (complete) (partial)

896.0-896.3

  

X

        

Traumatic amputation of leg(s) (complete) (partial)

897.0-897.7

  

X

        

Traumatic amputation of other finger(s) (complete) (partial)

886.0-886.1

  

X

        

Traumatic amputation of thumb (complete) (partial)

885.0-885.1

  

X

        

Traumatic amputation of toe(s) (complete) (partial)

895.0-895.1

  

X

        

Trigeminal nerve disorders (incl., Trigeminal neuralgia)

350.1-350.9

X

          

Ulcer of lower limbs, except decubitus ulcer

707.10-707.9

    

X

      

ICD-9-CM Surgical Procedure Code Description

ICD-9-CM Surgical Procedure Code

A 19 Days

B 11 Days

C 15 Days

D N/A*

E 16 Days

F 17 Days

Amputation of lower limb

84.10-84.19

  

X

        

Amputation of upper limb

84.00-84.09

  

X

        

Arthroplasty and repair of hand, fingers, and wrist

81.71-81.79

  

X

        

Arthroplasty and repair of shoulder and elbow

81.80-81.85

  

X

        

Excision of intervertebral disc

80.51

  

X

        

Excision or destruction of intervertebral disc, unspecified

80.50

  

X

        

Extracranial ventricular shunt

02.31-02.39

X

      

X

  

Five-in-one repair of knee

81.42

  

X

        

Incision of cerebral meninges

01.31

X

      

X

  

Intervertebral chemonucleolysis

80.52

  

X

        

Joint replacement of lower extremity

81.51-81.59

  

X

        

Mastectomy

85.41-85.48

  

X

        

Other craniectomy

01.25

X

      

X

  

Other craniotomy

01.24

X

      

X

  

Repair of cerebral meninges

02.11-02.14

X

      

X

  

Revision, removal, and irrigation of ventricular shunt

02.41-02.43

X

      

X

  

Rotator cuff repair

83.63

  

X

        

Spinal fusion

81.00-81.08

  

X

        

Triad knee repair

81.43

  

X

        
 
* Statement "D" does not apply to PT services.