Diagnosis Code Reference Tool Attachment C - Tufts Health Plan

Diagnosis Code Reference ToolAttachment C: ICD-9 Codes Determinedby US Family Health Plan to beInappropriate for Physical TherapyThe following list represents ICD-9 diagnosis codes for which US Family Health Plan has determined thatPhysical Therapy is not appropriate. US Family Health Plan will not reimburse for Physical Therapyservices billed with these codes.Note: All V codes will no longer be acceptable for billing for Physical Therapy. A specific diagnosis codemust be attached.ICD-9Diagnosis CodeDescription250.9 Diabetes with unspecified complication719.3 Palindromic rheumatism722.3 Schmorl’s nodes722.30 Schmorl’s nodes, unspecified region722.31 Schmorl’s nodes, thoracic region722.32 Schmorl’s nodes, lumbar region722.39 Schmorl’s nodes, other723.6 Panniculitis specified as affecting neck723.7 Ossification of posterior longitudinal ligament in cervical region724.7 Disorders of coccyx724.70 Unspecified disorder of coccyx724.71 Hypermobility of coccyx724.79 Other: coccygodynia734 Flat foot735 Acquired deformities of toe739 Nonallopathic lesions, not elsewhere classified739.0 Nonallopathic lesions, head region739.1 Nonallopathic lesions, cervical region739.2 Nonallopathic lesions, thoracic region739.3 Nonallopathic lesions, lumbar region739.4 Nonallopathic lesions, sacral region739.5 Nonallopathic lesions, pelvic region739.6 Nonallopathic lesions, lower extremities739.7 Nonallopathic lesions, upper extremities739.8 Nonallopathic lesions, rib cage739.9 Nonallopathic lesions, abdomen and other755.5 Other anomalies of upper limb, including shoulder girdle755.50 Unspecified anomaly of upper limb755.51 Congenital deformity of clavicle755.52 Congenital deformity of scapula755.53 Radioulnar synostosis755.54 Madelung’s deformity755.55 Acrocephalosyndactyly755.56 Accessory carpal bones755.57 Macrodactylia (fingers)755.58 Cleft hand, congenital755.59 Other anomalies of the upper limb755.61 Coxa valga, congenital755.62 Coxa vara congenital755.63 Other congenital deformity of hipOriginated 02/2006 1 of 2 Tufts Health Plan – USFHP Diagnosis Code Reference Tool Attachment C

ICD-9Diagnosis CodeDescription755.64 Congenital deformity of knee (joint)755.65 Macrodactylia of toes755.66 Other anomalies of toes755.67 Anomalies of foot, not elsewhere classified755.69 Other anomalies of the lower limb756.0 Anomalies of skull and face bones756.10 Anomaly of spine, unspecified756.14 Hemivertebra756.19 Other anomalies of the spine756.3 Other anomalies of ribs and sternum756.52 Osteopetrosis756.53 Osteopoikolosis756.54 Polyostotic fibrous dysplasia of bone756.55 Chondroectodermal dysplasia756.56 Multiple epiphyseal dysplasia756.59 Other osteodystrophies756.6 Anomalies of diaphragm756.7 Anomalies of abdominal wall756.9 Other and unspecified anomalies of musculoskeletal system784.0 Headache784.1 Throat pain784.6 Other symbolic dysfunction784.60 Symbolic dysfunction, unspecified784.61 Alexia and dyslexia784.69 Other: acalculia, agnosia, agraphia NOS, and apraxia784.7 Epistaxis784.8 Hemorrage from throat784.9 Other symptoms involving head and neck789 Other symptoms involving abdomen and pelvis789.0 Abdominal pain789.1 Hepatomegaly*Uniformed Services Family Health Plan Provider Services800-818-8589Originated 02/2006 2 of 2 Tufts Health Plan – USFHP Diagnosis Code Reference Tool Attachment C