Module 2 Assignment: Outpatient Evaluation Review

1. Look up the ICD-10 Dx Codes indicated on the sample evaluation using the CMS.gov (Links
to an external site.) website and list them. Are these diagnostic codes appropriate? Explain
why or why not.

o R27.9 – Unspecified lack of coordination: The child demonstrates difficulty with gross
and fine motor coordination skills, as well as bilateral integration and coordination. His
symptoms align with the ICD010 code R27.9, so it is an appropriate code to use.

o G90.9 – Disorder of the autonomic nervous system, unspecified: The child does present
with autonomic symptoms (history of breathing difficulties, GI issues), however both
conditions have well established specific origins (asthma, acid reflux/allergies). Given
that his autonomic symptoms are specific to his medical diagnosis, I do not feel that this
code is appropriate for this outpatient occupational therapy (OT) plan of care.

o Instead of the ICD10 code G90.9, I believe that a more appropriate code for diagnosis
would be F82.0 (dyspraxia). As per his evaluation, he experiences marked difficulty in all
assessed area of praxis skills to include constructional praxis, praxis on verbal command,
postural praxis, and sequencing praxis. His significant involvement in the area of praxis
skills is likely contributing to deficits in other areas. Conversely, another possible
diagnosis code may be M62.81 (generalized weakness) as he experiences generalized
weakness in fine and gross muscles that is mentioned in multiple instances throughout
his evaluation.

2. Based upon the information provided in the sample evaluation, write a summary statement
in 75-100 words to justify the need and rationale for OT services to meet standards for
reimbursement.

o The client is a sweet, intelligent second grade boy who experiences dysfunction in praxis
skills, strength and muscle tone, sensory processing, and ADL performance. Re-
evaluation results indicate he requires skilled outpatient OT services to facilitate
improved praxis for increased functional coordination, gross and fine motor skills, and
motor planning to improve occupational engagement in school and at home, as well as
 therapeutic strengthening and ADL training to facilitate independence in self-care tasks
with improved functional activity tolerance.

3. Create a prioritization of need areas by listing 2 areas of need.

o 1. Self-care skills/BADLs
2. Fine motor function

4. Create 2 long-term goals to address areas of need identified.

o LTG 1: To demonstrate improved endurance and attention to self-care tasks, Child will
complete an entire dressing sequence (including socks, shoes, shirt, and pants)
independently with minimal verbal cues on 4 out of 5 opportunities.

• STG 1: Child will display improved fine motor praxis skills and organization of
behavior by being able to tie his shoelaces with minimal verbal and visual cues
on 4 of 5 opportunities.

o LTG 2: To improve success in age-related school tasks, the child will demonstrate
improved fine motor and visual-motor integration skills by writing with appropriate
alignment and casing on 3 out of 5 trials.

• STG 1: Child will demonstrate improved fine motor function by grasping a pencil
with, and maintaining, a mature tripod grasp in 4 of 5 trials.

• STG 2: The child will demonstrate improved bilateral integration and motor
planning skills to use LUE to stabilize objects/paper during play activities and
writing tasks with minimal verbal cues 80% of the time.

5. Recommend a frequency for outpatient OT services (i.e. per week and length of session).

o Child will be seen at outpatient clinic for skilled OT services twice a week for 45 minutes.

6. Recommend a duration of treatment (length of time services are recommended to achieve

goals).
 o Child will be seen in the outpatient clinic for skilled OT services for 12 weeks to promote
functional strengthening, improved praxis skills, self-care performance, and family
training.

7. Make one referral to a home, community, or professional resources to further support the
child's participation in occupation and explain your rationale for each.

o Child will be referred for speech language pathology evaluation and participation in
community-based SLP-lead social skills training small group.