ICD-10-CM diagnosis coding for therapy claims

For OT, PT and SLP practices seeing children, adults or both: a therapy claim’s diagnosis codes come from the ICD-10-CM files and Official Guidelines in force on the date of service, the FY 2027 set from October 1, 2026. List first what the record shows therapy treats, code to full specificity, and never choose a code because it pays.⁠^1,2,3

What is ICD-10-CM, and which version applies to a therapy claim?

ICD-10-CM is the diagnosis code set HIPAA adopts for diseases, injuries, impairments and other health problems, and the version that applies is the one in force on the date of service. The regulation names ICD-10-CM, including the Official ICD-10-CM Guidelines for Coding and Reporting, for the period on and after October 1, 2015, and says each code set is valid within the dates its maintaining organization specifies.⁠⁴ CMS’s ICD-10 page puts the FY 2027 files in force for patient encounters from October 1, 2026 through September 30, 2027, and states that ICD-10 applies to all parties covered by HIPAA, not just providers who bill Medicare or Medicaid.⁠¹ The same code set therefore sits on a child’s Medicaid claim, an adult’s Medicare claim and a commercial claim for either.

CMS and the National Center for Health Statistics publish the Official Guidelines, adherence to them is required under HIPAA, and the instructions and conventions inside the code book take precedence over the guidelines.⁠⁵ Section I of the guidelines applies in every setting, and Section IV governs outpatient services and office visits, which is where an outpatient therapy practice’s claims fall.⁠^2,5

Which code-book conventions trip up therapy coding most often?

The ones that decide whether a code is complete and whether two codes may stand together. Each of these is written into the guidelines’ conventions or general rules:

• Index first, then the tabular list: find the term in the Alphabetic Index and confirm it in the Tabular List, because the full code, including laterality and any 7th character, can only be chosen in the tabular list.⁠³
• Every character: a three-character code is used only when it is not subdivided, a code short of its required characters is invalid, and a placeholder X fills the empty positions before a required 7th character.⁠^3,7
• Excludes1 and Excludes2: an Excludes1 note means the two codes are never used together, unless the two conditions are unrelated, while an Excludes2 note allows both codes when the patient has both conditions.⁠⁷
• Code first, use additional code, code also: the first two set the order, etiology before manifestation; a code-also note asks for two codes without setting their order.⁠⁷
• Other and unspecified: "other" codes are for documented detail with no specific code; "unspecified" codes are for a record that is not detailed enough for a more specific one.⁠⁷
• Laterality: with no bilateral code, report the left and right codes separately; the affected side may come from another clinician’s documentation; an unspecified side is for the rare record that cannot be clarified.⁠³
• Once per encounter: each unique code is reported only once for an encounter.⁠³

Who assigns the diagnosis code on a therapy claim?

The practitioner legally accountable for establishing the diagnosis, which for a medical diagnosis is usually the referring physician or other qualified practitioner, and for a treatment diagnosis may be the therapist where state law allows. The guidelines define the "provider" as the physician or other qualified health care practitioner legally accountable for establishing the patient’s diagnosis, and base code assignment on that provider’s documentation.⁠^3,5 Medicare’s manual asks the therapy evaluation for a diagnosis where state and local law allow one, says the treatment diagnosis may or may not be identified by the therapist depending on scope of practice, and, where a diagnosis is not allowed, asks for a condition description similar to the ICD code.⁠⁶

A few items may rest on other clinicians’ documentation, among them the affected side and social determinants of health, such as Z60.2, Problems related to living alone, for an adult whose injury limits daily activities at home and who is documented as living alone.⁠^3,14

Each profession’s association states its own position, and the state practice act is the law that decides:

• Physical therapy: APTA’s House of Delegates policy says physical therapists shall establish a diagnosis for each patient or client.⁠¹⁵
• Speech-language pathology: ASHA’s scope of practice says competent SLPs can diagnose communication and swallowing disorders but do not differentially diagnose medical conditions.⁠¹⁶
• Occupational therapy: AOTA’s public coding page urges occupational therapists to use ICD-10-CM accurately to code medical and treatment diagnoses to the highest level of specificity.⁠¹⁷

A medical diagnosis such as cerebral palsy, autism or a stroke reaches the therapy claim from the physician’s or other qualified practitioner’s documentation; the provider’s statement that the condition exists is sufficient, and code assignment does not turn on the clinical criteria behind it.⁠^6,7 Medicare also requires each discipline treating the same patient to establish its own diagnosis and goals independently.⁠⁶

What is the difference between a medical and a treatment diagnosis?

The medical diagnosis is the condition a physician or other practitioner documents; the treatment diagnosis describes the impairment therapy treats, and Medicare says both are often relevant.⁠⁶ The manual’s example is a physician’s diagnosis of stroke, for which the treatment diagnosis or condition description might be abnormality of gait for PT, hemiparesis for OT and dysphagia for SLP, with the body part named for PT and OT.⁠⁶ CGS, the Medicare contractor for Kentucky and Ohio, repeats the same distinction in its PT and OT billing article.⁠¹⁰

The manual’s example describes the idea; the code book decides the code. After a stroke, the tabular list sends hemiparesis to the I69.35 codes, the R47.01 aphasia code excludes aphasia following cerebrovascular disease, and the R13.1 dysphagia codes carry a note to code first dysphagia following cerebrovascular disease.⁠⁸ The sections on adult codes and stroke sequelae below work through those notes.

Which outpatient coding rules apply to therapy evaluations and visits?

Section IV of the Official Guidelines, read together with Section I; six rules from the two shape a therapy claim.⁠^2,3

1. List the chief reason first. For an encounter for therapeutic services only, sequence first the diagnosis, condition, problem or other reason the record shows to be chiefly responsible for the services, and list coexisting conditions after it.⁠²
2. Leave uncertainty out. Do not code a diagnosis written as probable, suspected, questionable, rule out, compatible with, consistent with or working diagnosis; code the signs, symptoms or other reason for the visit to the highest degree of certainty instead. The inpatient rules on inconclusive diagnoses do not apply to outpatients.⁠²
3. Use signs and symptoms while a diagnosis is pending. Symptom codes are acceptable when the provider has not established a diagnosis, and the guidelines note that a diagnosis may take two or more visits to confirm.⁠²
4. Do not add what the diagnosis already says. Signs routinely part of a disease are not coded in addition to it; signs not routinely associated with it are coded when present.⁠³
5. Code to the specificity the record supports. Use the highest level of specificity the documentation supports, and use an unspecified code when it is the most accurate statement of what is known, never a specific code the record does not support.⁠^2,3
6. Code chronic and coexisting conditions that matter. A chronic condition may be coded at each visit where it is treated, and coexisting conditions are coded when they affect care; conditions treated earlier that no longer exist are not.⁠²

ASHA’s coding guidance agrees: an evaluation to "rule out" a condition is not a coding convention, and when results are normal the signs and symptoms, chief complaint or reason for the encounter are reported instead.⁠¹⁸

Should the medical or the treatment diagnosis be listed first?

Usually the code for what therapy is treating, unless a code-book instruction or the payer directs otherwise. Medicare’s claims manual says to bill the most relevant diagnosis, the code that best relates to the reason for treatment: for gait training after an amputation in a patient with diabetes, abnormality of gait is preferred because it characterizes the treatment.⁠¹⁹ It also asks practices to avoid vague diagnoses, to put the therapy code in another position when the physician’s diagnosis must come first, and to keep complicating conditions in secondary positions.⁠¹⁹

For speech-language pathology, ASHA’s guidance makes the treating diagnosis first-listed and the medical diagnosis that causes or contributes to it second, and says to follow a payer or facility that asks for the reverse.⁠¹⁸ A code-first note outranks any of these preferences: dysphagia after a stroke is listed as the I69 dysphagia code first, then the R13.1 code for its phase.⁠^7,8

Which ICD-10-CM codes come up in pediatric therapy practices?

The developmental speech, language and motor codes of chapter 5, the symptom codes for delayed development and feeding in chapter 18, and the neurological and congenital codes a referral carries; each has notes that limit what may be reported with it.⁠¹³ The table lists titles as the FY 2027 tabular list prints them.

The index decides between neighbors. "Delay, development" defaults to R62.50, with global delay at F88, language and speech delay at F80.9 and a delayed milestone at R62.0; "Dyspraxia" defaults to R27.8, Other lack of coordination, and developmental dyspraxia goes to F82.⁠⁹ Because F82 excludes the R26 and R27 codes, a child with a documented developmental coordination disorder takes F82 alone, not F82 with a coordination or gait symptom code.⁠^7,13

Autism and speech codes need care. The R47 speech disturbance codes carry an Excludes1 note for autism (F84.0), and ASHA’s guidance has the SLP list first the speech-language disorder treated, such as R48.8 for language deficits with an organic basis, with F84.0 second; for an autistic child with an articulation disorder it advises F80.0 with the autism code because of the R47 note, a step ASHA itself calls contrary to its standard guidance and the only option until the note is corrected.⁠^13,18 ASHA also says SLPs can diagnose apraxia and that R48.2 is one of the few R codes an SLP can assign without a secondary medical condition.⁠¹⁸ The speech therapy CPT codes guide covers the procedure side, and the apraxia of speech page and autism hub describe the conditions for families.

For a feeding disorder with dysphagia, the R63.31 and R63.32 codes take a dysphagia code as well, and the 92526 guide sets out which procedure code fits which feeding service.⁠¹³

Is there an ICD-10-CM code for sensory processing disorder?

No. Neither the FY 2027 index nor the tabular list contains the phrase sensory processing or sensory integration.⁠⁹ The claim carries what the occupational therapy evaluation and the physician’s record actually support, coded under the same outpatient rules as any other visit.⁠² The sensory processing hub sets out the condition’s status in the diagnostic manuals with its own sources, and the 97533 sensory integration guide covers the procedure code and how payers treat it.

How do congenital and perinatal codes from a referral carry into therapy?

They stay usable for as long as the condition does. Chapter 17 congenital codes may be used throughout the patient’s life, chapter 16 perinatal codes may be used throughout life while the condition is still present, and the P07 prematurity and low birth weight codes are for a child or adult whose prematurity still affects their current health.⁠¹⁴ When a congenital condition has no unique code, the guidelines ask for codes for its manifestations, and the Down syndrome codes ask for an additional code for any associated degree of intellectual disability.⁠^13,14

Torticollis shows why the congenital and acquired forms matter. The index sends torticollis to M43.6 and congenital sternomastoid torticollis to Q68.0, and M43.6 carries an Excludes1 note for the congenital form, so an infant referred for congenital (sternomastoid) torticollis is coded Q68.0.⁠^9,13 Families can read about the condition on the torticollis page, and the cerebral palsy and Down syndrome pages cover two diagnoses pediatric referrals often carry.

Which ICD-10-CM codes come up in adult therapy practices?

Stroke sequelae in category I69, the chapter 18 symptom codes for gait, falls, cognition, swallowing and speech, musculoskeletal codes by site and side, injury codes with a 7th character, and aftercare Z codes.⁠^8,14 Titles below are as the FY 2027 tabular list prints them.

Falls have their own guideline. R29.6, Repeated falls, is for a patient who has recently fallen while the reason is being investigated; Z91.81, History of falling, is for a patient who fell in the past and is at risk of falling again; and the two may be reported together when both apply.⁠¹⁴ Musculoskeletal codes in chapter 13 mostly carry a site and a side, chronic or recurrent conditions are generally coded there, and a current acute injury goes to the injury codes of chapter 19.⁠¹⁴ The PT evaluation codes guide and the OT evaluation codes guide cover the evaluation side of these visits.

How do stroke sequelae codes in category I69 work for therapy?

They describe the deficits a stroke or other cerebrovascular disease leaves behind, which may be present from the onset or appear later, and there is no time limit on using a sequela code.⁠^3,14 The code for the acute phase is not reported beside its late effect, except that I69 codes may sit with a code for a current cerebrovascular disease when the patient also has deficits from an older one.⁠^3,14 A patient with no remaining neurologic deficit takes Z86.73, a personal history code, not an I69 code.⁠^8,14

The hemiplegia, hemiparesis and monoplegia codes say whether the dominant or nondominant side is affected. When the record names the side but not dominance, the defaults are dominant for an ambidextrous patient, nondominant when the left side is affected and dominant when the right side is affected.⁠¹⁴ Record hand dominance at the evaluation so the code does not rest on a default.

The symptom codes step aside for I69. R47.01 for aphasia, R48.2 for apraxia and the R41.84 cognitive deficit codes each exclude their post-stroke forms, so aphasia after a cerebral infarction is I69.320, not R47.01.⁠⁸ Dysphagia works in pairs: R13.1 says to code first the I69 dysphagia code, and I69.391 asks for an additional R13.1 code for the phase, which ASHA’s guidance describes for SLPs in the same terms.⁠^8,18 The stroke recovery page, the aphasia page and the dysphagia page describe these conditions for patients and families.

Which seventh character fits therapy after an injury or fracture?

Usually D, subsequent encounter, which the guidelines reserve for encounters after active treatment is complete, while the patient receives routine care during healing or recovery.⁠¹⁴ The 7th character follows whether the patient is still in active treatment, not whether the clinician is seeing the patient for the first time, so a new therapist does not make an encounter "initial".⁠¹⁴

Injuries do not take aftercare Z codes: for aftercare of an injury, the guidelines assign the injury code with 7th character D, and the Z47 orthopedic aftercare category excludes aftercare for a healing fracture.⁠^8,14 Fracture codes have more 7th characters than other injuries; for the femur fracture codes, D reads "subsequent encounter for closed fracture with routine healing".⁠⁸ Rehabilitation after a joint replacement for arthritis is different: Z47.1, Aftercare following joint replacement surgery, takes an additional code for the joint, such as Z96.651 for a right artificial knee.⁠⁸

Do payers cover therapy only for certain diagnosis codes?

Some do, for some services, and the lists differ by contractor, discipline and payer; a code on a list never makes a service covered, and no list justifies choosing a code. Two articles from one Medicare contractor show the range: CGS’s Jurisdiction 15 billing article for outpatient PT and OT, effective June 4, 2026, lists no covered diagnosis codes; its one list names 773 codes that do not support medical necessity for a single modality code, 97035, and it says the diagnosis code must best describe the condition for which the service was performed.⁠¹⁰ The same contractor’s speech-language pathology article, effective August 6, 2026, lists 415 codes in two groups and states that the correct use of a code does not assure coverage.⁠¹¹

Find the article of the contractor that processes the practice’s claims, save the version with its effective date, and check it when it changes. For a Medicare Advantage plan, prior authorization may be used to confirm the diagnoses or other medical criteria a coverage decision rests on, or that a basic benefit is medically necessary, and an approval given that way cannot later be denied for lack of medical necessity.⁠²⁰ Commercial plans state their own diagnosis rules in their policies; the 97533 guide shows one plan’s list of diagnoses it does not cover for a service.

The service and the record drive the code, never the list. The guidelines call it inappropriate to select a specific code the medical record does not support, Medicare’s evaluation asks for a diagnosis as specific and relevant to the problem treated as possible, and the correct coding manual says different diagnoses are not adequate grounds for modifier 59.⁠^3,6,21 The therapy modifiers guide covers when 59 does apply. When a payer’s list leaves out the condition the record supports, the answer is a call to the payer, an appeal or a conversation with the patient or family, not a different code.

What happens when a claim carries an outdated or invalid code?

It comes back. CGS’s article states that a claim submitted without a valid ICD-10-CM code is returned to the provider as incomplete, and the guidelines call a code invalid when it lacks any of its required characters.⁠^3,10 Validity depends on the date of service: HIPAA makes each code set valid within the dates its maintaining organization sets, and CMS’s ICD-10 page assigns each release to encounters by date, the FY 2027 files to encounters from October 1, 2026 through September 30, 2027.⁠^1,4 APTA describes the cycle as a yearly update used from October 1 through September 30, and CMS’s page also carries April 1, 2026 files for encounters from April through September 2026, so a mid-year release is possible as well.⁠^1,22

Plantar fasciitis shows how an update breaks a saved code. In the April 1, 2026 files, plantar fasciitis indexed to M72.2, Plantar fascial fibromatosis, a complete code that listed plantar fasciitis among its terms.⁠¹² In the FY 2027 files, M72.2 became a header with subcodes M72.20 to M72.22 for fibromatosis, and plantar fasciitis moved to its own codes, M67.A01 for the right foot, M67.A02 for the left and M67.A09 for an unspecified foot.⁠^9,12 A PT practice whose template still says M72.2 sends an invalid code for every visit on or after the first day of FY 2027.⁠³

Manuals lag the code set too: Medicare’s own therapy documentation section still prints an ICD-9-CM code, 787.2, in one of its examples, so a manual’s example is not a code source.⁠⁶ Check saved codes in the record system, the billing system’s favorites and any intake forms against the new files each October and whenever CMS posts an April release.

How do Medicaid and EPSDT treat the diagnosis on a child’s claim?

The same ICD-10-CM rules apply, but the question EPSDT asks is whether a service is medically necessary for the child, which states decide case by case. EPSDT covers children under 21 enrolled in Medicaid and requires states to provide any service coverable under section 1905(a) that is found medically necessary to treat, correct or reduce a condition, even when the state plan does not list it.⁠²³ The coded diagnosis supports the request, and the evaluation’s findings about the child’s function carry it. The EPSDT coverage guide covers what to document and how to ask, and the Medicaid enrollment guide covers joining a state program. A state Medicaid program or managed care plan can publish its own diagnosis requirements, so read its provider manual for the codes it lists.

Early intervention and school services use eligibility categories, not diagnosis codes. Part C of IDEA defines an eligible infant or toddler by a developmental delay measured with appropriate diagnostic instruments, or by a diagnosed condition with a high probability of resulting in delay, and Part B defines a child with a disability by categories such as speech or language impairment, together with a need for special education and related services.⁠²⁴ An IEP category or an early intervention eligibility finding is not an ICD-10-CM code, and the clinic claim still needs one. The IEP team guide covers where outpatient care fits beside school services.

How does Medicare use the diagnosis on an adult’s plan of care?

The plan of care must indicate it. Under 42 CFR 410.61, an outpatient PT, OT or SLP plan of treatment prescribes the type, amount, frequency and duration of services and indicates the diagnosis and anticipated goals, and the certification under 42 CFR 424.24(c) attests that the services were furnished under a plan meeting that section, with recertification at least every 90 days.⁠^25,26 The Benefit Policy Manual lists diagnoses first among the plan’s minimum contents and treats diagnoses as one way to show the complexities that shape treatment.⁠⁶

Each discipline writes its own plan with its own diagnosis, so a patient seeing PT and SLP after a stroke has two plans and two first-listed codes.⁠⁶ When an evaluation is the only service, it serves as the plan of care if it contains a diagnosis or, in a state where the therapist may not diagnose, a description of the condition from which the referring practitioner can determine one.⁠⁶ Medicare Advantage plans and commercial plans set their own requirements in their manuals and contracts, and the patient’s side of these rules is in the Medicare therapy coverage guide. What a reviewer checks in the plan, the notes and the progress reports is in the documentation audit guide.

What should a practice do when the referral’s diagnosis does not fit?

Code what the record supports, and query the referring practitioner about the rest. The guidelines tell coders to query the provider when documentation conflicts, and when it is unclear whether two conditions under an Excludes1 note are related.⁠⁷ They also make the provider’s statement that a condition exists sufficient for coding, so the therapist does not re-diagnose a medical condition; a finding that points elsewhere goes back to the physician as a question.⁠⁷ A referral that reads "rule out" or "suspected" is coded by its signs and symptoms until a diagnosis is confirmed.⁠²

Typical mismatches are a code that is no longer valid, a side that differs from the evaluation, an acute code months after the event, or a general symptom where the physician’s notes name a specific condition. The affected side may be taken from other clinicians’ documentation, but conflicting records on the side go to the provider as a query.⁠³

Which code family fits which clinical situation?

The situation decides the guideline, the guideline decides the code family, and the note has to show the facts that connect them. The rows are examples to read with the code book, not a list of codes to assign.

How do you keep a diagnosis reference register for the practice?

Keep one row for each code the practice reports often, with its title from the current files, the notes that limit it, where the diagnosis comes from, and the day someone last checked it against the files. Treat the register as a navigation aid, not a standing order: the patient’s record still decides each claim, and an unspecified or symptom code is right when it is what the record supports.⁠³ Re-check every row when CMS posts a new release, since the files apply by date of service.⁠¹

What belongs on a code check for each new plan of care?

Every step that decides whether the codes on the plan are valid, supported and in the right order. Run it once for each discipline’s plan, because each plan carries its own diagnosis.⁠⁶

How would one child’s and one adult’s diagnoses be coded?

From the record outward: what the referral says, what the evaluation finds, which guideline applies, then the codes. Both cases are hypothetical, and their details are inputs, not statements about any real patient or plan.

The OT procedure codes guide and the eight-minute rule guide cover the procedure lines that sit beside these diagnoses on the same claims.

Sources

1. Centers for Medicare & Medicaid Services. ICD-10 Codes (page last modified September 8, 2026; its 2027 ICD-10-CM files section and its FY 2026 April 1 files). Checked October 26, 2026.
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   “CDC announces new ICD-10-CM codes effective October 1, 2026.”; “Use these files for discharges occurring from October 1, 2026 – September 30, 2027 and for patient encounters occurring from October 1, 2026 – September 30, 2027.”; “ICD-10 applies to all parties covered by the Health Insurance Portability and Accountability Act (HIPAA), not just providers who bill Medicare or Medicaid.”; “These files include updates for FY 2026. Use these codes for discharges occurring from April 1, 2026 – September 30, 2026, and for patient encounters occurring from April 1, 2026– September 30, 2026.”. The last passage introduces the April 1, 2026 code files posted beside the October 1, 2025 ones.
2. Centers for Medicare & Medicaid Services and the National Center for Health Statistics. ICD-10-CM Official Guidelines for Coding and Reporting, FY 2027 (Section IV, Diagnostic Coding and Reporting Guidelines for Outpatient Services). Checked October 26, 2026.
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   “These coding guidelines for outpatient diagnoses have been approved for use by hospitals/ providers in coding and reporting hospital-based outpatient services and provider-based office visits.”; “Coding guidelines for inconclusive diagnoses (probable, suspected, rule out, etc.) were developed for inpatient reporting and do not apply to outpatients.”; “In the outpatient setting, the term first-listed diagnosis is used in lieu of principal diagnosis.”; “Diagnoses often are not established at the time of the initial encounter/visit. It may take two or more visits before the diagnosis is confirmed.”; “Never begin searching initially in the Tabular List as this will lead to coding errors.”; “Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a diagnosis has not been established (confirmed) by the provider.”; “Code to the highest level of specificity when supported by the medical record documentation.”; “List first the ICD-10-CM code for the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the services provided. List additional codes that describe any coexisting conditions.”; “Do not code diagnoses documented as “probable”, “suspected,” “questionable,” “rule out,” “compatible with,” “consistent with,” or “working diagnosis” or other similar terms indicating uncertainty.”; “Chronic diseases treated on an ongoing basis may be coded and reported as many times as the patient receives treatment and care for the condition(s).”; “Code all documented conditions that coexist at the time of the encounter/visit and that require or affect patient care, treatment or management. Do not code conditions that were previously treated and no longer exist.”; “For patients receiving therapeutic services only during an encounter/visit, sequence first the diagnosis, condition, problem, or other reason for encounter/visit shown in the medical record to be chiefly responsible for the outpatient services provided during the encounter/visit.”.
3. Centers for Medicare & Medicaid Services and the National Center for Health Statistics. ICD-10-CM Official Guidelines for Coding and Reporting, FY 2027 (Section I.B, General Coding Guidelines: items 1, 2, 4, 5, 6, 10, 12, 13, 14 and 18). Checked October 26, 2026.
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   “first locate the term in the Alphabetic Index, and then verify the code in the Tabular List.”; “Selection of the full code, including laterality and any applicable 7th character can only be done in the Tabular List.”; “Diagnosis codes are to be used and reported at their highest number of characters available and to the highest level of specificity documented in the medical record.”; “A three-character code is to be used only if it is not further subdivided. A code is invalid if it has not been coded to the full number of characters required for that code, including the 7th character, if applicable.”; “Codes that describe symptoms and signs, as opposed to diagnoses, are acceptable for reporting purposes when a related definitive diagnosis has not been established (confirmed) by the provider.”; “Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification.”; “Additional signs and symptoms that may not be associated routinely with a disease process should be coded when present.”; “A sequela is the residual effect (condition produced) after the acute phase of an illness or injury has terminated. There is no time limit on when a sequela code can be used.”; “The code for the acute phase of an illness or injury that led to the sequela is never used with a code for the late effect.”; “Each unique ICD-10-CM diagnosis code may be reported only once for an encounter.”; “If no bilateral code is provided and the condition is bilateral, assign separate codes for both the left and right side.”; “When laterality is not documented by the patient’s provider, code assignment for the affected side may be based on medical record documentation from other clinicians.”; “If there is conflicting medical record documentation regarding the affected side, the patient’s provider should be queried for clarification.”; “Codes for “unspecified” side should rarely be used, such as when the documentation in the record is insufficient to determine the affected side and it is not possible to obtain clarification.”; “Code assignment is based on the documentation by the patient's provider (i.e., physician or other qualified healthcare practitioner legally accountable for establishing the patient's diagnosis).”; “Social determinants of health (SDOH) classified to Chapter 21”; “Unspecified codes should be reported when they are the codes that most accurately reflect what is known about the patient’s condition at the time of that particular encounter.”; “It would be inappropriate to select a specific code that is not supported by the medical record documentation or conduct medically unnecessary diagnostic testing in order to determine a more specific code.”. The SDOH passage is one line of the list of exceptions in item 14, beside laterality.
4. Electronic Code of Federal Regulations. 45 CFR 162.1002, Medical data code sets and 45 CFR 162.1011, Valid code sets (HIPAA administrative simplification; read through the eCFR versioner as of October 22, 2026, the title’s latest issue). Checked October 26, 2026.
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   “Current Procedural Terminology, Fourth Edition (CPT-4), as maintained and distributed by the American Medical Association, for physician services and other health care services.”; “For the period on and after October 1, 2015:”; “International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) (including The Official ICD-10-CM Guidelines for Coding and Reporting), as maintained and distributed by HHS, for the following conditions:”; “Each code set is valid within the dates specified by the organization responsible for maintaining that code set.”. The CPT passage is paragraph (a)(5), which paragraph (c)(1) keeps in force for the period on and after October 1, 2015.
5. Centers for Medicare & Medicaid Services and the National Center for Health Statistics. ICD-10-CM Official Guidelines for Coding and Reporting, FY 2027 (updated October 1, 2026, for October 1, 2026 to September 30, 2027; introduction and Section I). Checked October 26, 2026.
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   “The Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS), two departments within the U.S. Federal Government’s Department of Health and Human Services (DHHS) provide the following guidelines for coding and reporting using the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM).”; “The instructions and conventions of the classification take precedence over guidelines.”; “Adherence to these guidelines when assigning ICD-10-CM diagnosis codes is required under the Health Insurance Portability and Accountability Act (HIPAA).”; “A joint effort between the healthcare provider and the coder is essential to achieve complete and accurate documentation, code assignment, and reporting of diagnoses and procedures.”; “In the context of these guidelines, the term provider is used throughout the guidelines to mean physician or any qualified health care practitioner who is legally accountable for establishing the patient’s diagnosis.”; “The conventions, general guidelines and chapter-specific guidelines are applicable to all health care settings unless otherwise indicated.”.
6. Centers for Medicare & Medicaid Services. Medicare Benefit Policy Manual, Chapter 15, Covered Medical and Other Health Services (Pub. 100-02, Rev. 13889, issued July 30, 2026; §220 definitions, §220.1.2 and §220.3). Checked October 26, 2026.
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   “Complexities may be represented by diagnoses (ICD codes), by patient factors such as age, severity, acuity, multiple conditions, and motivation, or by the patient’s social circumstances such as the support of a significant other or the availability of transportation to therapy.”; “The plan of care shall contain, at minimum, the following information as required by regulation (42CFR424.24, 410.61, and 410.105(c) (for CORFs)).”; “Diagnoses;”; “There shall be different plans of care for each type of therapy discipline. When more than one discipline is treating a patient, each must establish a diagnosis, goals, etc. independently.”; “Only a clinician may perform an initial examination, evaluation, re-evaluation and assessment or establish a diagnosis or a plan of care.”; “A diagnosis (where allowed by state and local law) and description of the specific problem(s) to be evaluated and/or treated. The diagnosis should be specific and as relevant to the problem to be treated as possible. In many cases, both a medical diagnosis (obtained from a physician/NPP) and an impairment based treatment diagnosis related to treatment are relevant. The treatment diagnosis may or may not be identified by the therapist, depending on their scope of practice. Where a diagnosis is not allowed, use a condition description similar to the appropriate ICD code. For example the medical diagnosis made by the physician is CVA; however, the treatment diagnosis or condition description for PT may be abnormality of gait, for OT, it may be hemiparesis, and for SLP, it may be dysphagia. For PT and OT, be sure to include body part evaluated.”; “the evaluation serves as the plan of care if it contains a diagnosis, or in states where a therapist may not diagnose, a description of the condition from which a diagnosis may be determined by the referring physician/NPP.”; “Example: The Plan states diagnosis is 787.2- Dysphagia secondary to other late effects of CVA.”. The last passage is an example in §220.3 that still prints an ICD-9-CM code.
7. Centers for Medicare & Medicaid Services and the National Center for Health Statistics. ICD-10-CM Official Guidelines for Coding and Reporting, FY 2027 (Section I.A, Conventions for the ICD-10-CM: items 2, 4, 5, 9, 12, 13, 17 and 19). Checked October 26, 2026.
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   “A code that has an applicable 7th character is considered invalid without the 7th character.”; “Where a placeholder exists, the X must be used in order for the code to be considered a valid code.”; “If a code that requires a 7th character is not 6 characters, a placeholder X must be used to fill in the empty characters.”; “Codes titled “other” or “other specified” are for use when the information in the medical record provides detail for which a specific code does not exist.”; “Codes titled “unspecified” are for use when the information in the medical record is insufficient to assign a more specific code.”; “An Excludes1 note indicates that the code excluded should never be used at the same time as the code above the Excludes1 note.”; “An exception to the Excludes1 definition is the circumstance when the two conditions are unrelated to each other. If it is not clear whether the two conditions involving an Excludes1 note are related or not, query the provider.”; “When an Excludes2 note appears under a code, it is acceptable to use both the code and the excluded code together, when appropriate.”; “These instructional notes indicate the proper sequencing order of the codes, etiology followed by manifestation.”; “A “code also” note instructs that two codes may be required to fully describe a condition, but this note does not provide sequencing direction.”; “The assignment of a diagnosis code is based on the provider’s diagnostic statement that the condition exists. The provider’s statement that the patient has a particular condition is sufficient.”; “If there is conflicting medical record documentation, query the provider.”.
8. National Center for Health Statistics, distributed by CMS. 2027 Code Tables, Tabular and Index (ZIP) (FY 2027 ICD-10-CM Tabular List, file icd10cm_tabular_2027.xml; code titles and instructional notes as the file prints them). Checked October 26, 2026.
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   I69 “Sequelae of cerebrovascular disease”, Excludes1 “personal history of cerebral infarction without residual deficit (Z86.73)”; I69.3 “Sequelae of cerebral infarction”, inclusion term “Sequelae of stroke NOS”; I69.320 “Aphasia following cerebral infarction”; I69.351 “Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side”; I69.354 “Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side”; I69.391 “Dysphagia following cerebral infarction”, use-additional-code note “code to identify the type of dysphagia, if known (R13.11-R13.19)”; I69.312 “Visuospatial deficit and spatial neglect following cerebral infarction”; R13.1 “Dysphagia”, code-first note “, if applicable, dysphagia following cerebrovascular disease (I69. with final characters -91)”; R13.12 “Dysphagia, oropharyngeal phase”; R47.01 “Aphasia”, Excludes1 “aphasia following cerebrovascular disease (I69. with final characters -20)”; R41.84 “Other specified cognitive deficit”, Excludes1 “cognitive deficits as sequelae of cerebrovascular disease (I69.01-, I69.11-, I69.21-, I69.31-, I69.81-, I69.91-)”; R41.840 “Attention and concentration deficit”, Excludes1 “attention-deficit hyperactivity disorders (F90.-)”; R41.841 “Cognitive communication deficit”; R48.2 “Apraxia”, Excludes1 “apraxia following cerebrovascular disease (I69. with final characters -90)”; R26 “Abnormalities of gait and mobility”, R26.2 “Difficulty in walking, not elsewhere classified” with Excludes1 “falling (R29.6)”, R26.81 “Unsteadiness on feet”, R26.89 “Other abnormalities of gait and mobility”; R27.8 “Other lack of coordination”; R29.6 “Repeated falls”, Excludes2 “history of falling (Z91.81)”; Z91.81 “History of falling”, inclusion term “At risk for falling”; M62.81 “Muscle weakness (generalized)”, Excludes1 “muscle weakness in sarcopenia (M62.84)”; Z47 “Orthopedic aftercare”, Excludes1 “aftercare for healing fracture-code to fracture with 7th character D”; Z47.1 “Aftercare following joint replacement surgery”, use-additional-code note “code to identify the joint (Z96.6-)”; Z96.651 “Presence of right artificial knee joint”; S72 “Fracture of femur”, whose 7th character D reads “subsequent encounter for closed fracture with routine healing”; Z86.73 “Personal history of transient ischemic attack (TIA), and cerebral infarction without residual deficits”, Excludes1 “sequelae of cerebrovascular disease (I69.-)”.
9. National Center for Health Statistics, distributed by CMS. 2027 Code Tables, Tabular and Index (ZIP) (FY 2027 ICD-10-CM Index to Diseases and Injuries, file icd10cm_index_2027.xml, and Tabular List, file icd10cm_tabular_2027.xml). Checked October 26, 2026.
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   Index entries as printed (term, subterm, code): “Dyspraxia R27.8”; “developmental (syndrome) F82”; “Delay, delayed” with “development R62.50”, “global F88”, “language F80.9”, “milestone R62.0” and “speech F80.9”; “Apraxia (classic) (ideational) (ideokinetic) (ideomotor) (motor) (verbal) R48.2”, subterm “cerebral infarction I69.390” under “following” “cerebrovascular disease”; “Torticollis (intermittent) (spastic) M43.6”, subterm “congenital (sternomastoid) Q68.0”; “Gait abnormality R26.9”, subterms “unsteadiness R26.81” and “falling R29.6”; “Fasciitis” “plantar (foot) M67.A0-”; “Toe” “see condition”; “Walking” “difficulty R26.2”. Neither the index nor the tabular list contains the phrase sensory processing or sensory integration, and the index has no main term for either; neither file has an entry for toe walking.
10. CGS Administrators, LLC, Medicare Administrative Contractor for Jurisdiction 15. Billing and Coding: Outpatient Physical and Occupational Therapy Services (A57067, version 34) (billing and coding article, effective June 4, 2026, last updated May 29, 2026; read through CMS’s Medicare Coverage Database API). Checked October 26, 2026.
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    “A claim submitted without a valid ICD-10-CM diagnosis code will be returned to the provider as an incomplete claim under Section 1833(e) of the Social Security Act.”; “The diagnosis code(s) must best describe the patient's condition for which the service was performed.”; “In many cases, both a medical diagnosis (obtained from the physician/NPP) and an impairment-based treatment diagnosis are relevant.”; “The following ICD-10-CM Codes do not support the medical necessity for the CPT/HCPCS code 97035.”. The article lists no covered ICD-10-CM codes; its one diagnosis list is the 773 codes under the last passage. CGS’s Jurisdiction 15 Part B home page describes it as the “Jurisdiction 15 A/B MAC for the states of KY & OH”.
11. CGS Administrators, LLC, Medicare Administrative Contractor for Jurisdiction 15 (Kentucky and Ohio). Billing and Coding: Speech-Language Pathology (A57040, version 26) (billing and coding article, effective August 6, 2026, last updated July 27, 2026; read through CMS’s Medicare Coverage Database API). Checked October 26, 2026.
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    “It is the responsibility of the provider to code to the highest level specified in the ICD-10-CM. The correct use of an ICD-10-CM code does not assure coverage of a service.”; “The service must be reasonable and necessary in the specific case and must meet the criteria specified in this determination.”; “*ICD-10 codes are secondary diagnoses for the coverage of cognitive or speech-language pathology services”. The article’s two groups of ICD-10-CM codes that support medical necessity hold 415 codes, 142 in group 1 and 273 in group 2, which is headed 96125; group 1 includes F80.0, F80.1, F80.2, F80.81, F82, F88, R47.01, R48.2 and I69.320, and group 2 includes R41.841; neither group lists F80.9. The last passage is the group 2 asterisk note.
12. National Center for Health Statistics, distributed by CMS. 2027 Code Descriptions in Tabular Order (ZIP) (order-file addenda, icd10cm_order_addenda_2027.txt, where a 1 marks a code valid for reporting and a 0 a header), compared with the April 1, 2026 Code Tables, Tabular and Index (ZIP) (FY 2026 files for encounters from April 1, 2026 to September 30, 2026). Checked October 26, 2026.
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    2027 addenda lines: “Delete: 1 M722 Plantar fascial fibromatosis”; “Add: 0 M722 Plantar fascial fibromatosis”; “Add: 1 M7221 Plantar fascial fibromatosis, right foot”; “Add: 1 M67A01 Plantar fasciitis, right foot”; “Add: 1 M67A02 Plantar fasciitis, left foot”; “Add: 1 M67A09 Plantar fasciitis, unspecified foot”. In the April 1, 2026 index the entry “Fasciitis” “plantar” reads M72.2, and the April 1, 2026 tabular list prints M72.2 “Plantar fascial fibromatosis” with the inclusion term “Plantar fasciitis” and no subcodes; the FY 2027 tabular list prints M72.2 with subcodes M72.20 to M72.22.
13. National Center for Health Statistics, distributed by CMS. 2027 Code Tables, Tabular and Index (ZIP) (FY 2027 ICD-10-CM Tabular List, file icd10cm_tabular_2027.xml; code titles and instructional notes as the file prints them). Checked October 26, 2026.
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    F80.0 “Phonological disorder”, Excludes1 “speech articulation impairment due to apraxia (R48.2)”; F80.1 “Expressive language disorder”, Excludes1 “mixed receptive-expressive language disorder (F80.2)” and Excludes2 “pervasive developmental disorders (F84.-)”; F80.2 “Mixed receptive-expressive language disorder”, Excludes1 “central auditory processing disorder (H93.25)”; F80.4 “Speech and language development delay due to hearing loss”, code-also note “type of hearing loss (H90.-, H91.-)”; F80.81 “Childhood onset fluency disorder”, Excludes1 “adult onset fluency disorder (F98.5)”; F80.82 “Social pragmatic communication disorder”, Excludes1 “autistic disorder (F84.0)”; F80.9 “Developmental disorder of speech and language, unspecified”; F82 “Specific developmental disorder of motor function”, inclusion term “Developmental coordination disorder”, Excludes1 “abnormalities of gait and mobility (R26.-)” and “lack of coordination (R27.-)”; F84 “Pervasive developmental disorders”, code-also note “any associated medical condition and intellectual disabilities”; F84.0 “Autistic disorder”, inclusion term “Autism spectrum disorder”; F88 “Other disorders of psychological development”, inclusion term “Global developmental delay”; R62.0 “Delayed milestone in childhood”, inclusion terms “Late talker” and “Late walker”; R62.50 “Unspecified lack of expected normal physiological development in childhood”; R63.3 “Feeding difficulties”, Excludes2 “eating disorders (F50.-)” and “feeding problems of newborn (P92.-)”; R63.31 “Pediatric feeding disorder, acute” and R63.32 “Pediatric feeding disorder, chronic”, each with a code-also note naming “dysphagia (R13.1-)”; R47 “Speech disturbances, not elsewhere classified”, Excludes1 “autism (F84.0)” and “specific developmental disorders of speech and language (F80.-)”; R48.2 “Apraxia”; R48.8 “Other symbolic dysfunctions”; G80 “Cerebral palsy”, Excludes1 “hereditary spastic paraplegia (G11.4)”, G80.1 “Spastic diplegic cerebral palsy”; Q90 “Down syndrome”, use-additional-code note “code(s) to identify any associated degree of intellectual disabilities (F70-F79)”; M43.6 “Torticollis”, Excludes1 “congenital (sternomastoid) torticollis (Q68.0)”; Q68.0 “Congenital deformity of sternocleidomastoid muscle”, inclusion term “Congenital (sternomastoid) torticollis”. Excludes1, Excludes2, inclusion term, code-also, code-first and use-additional-code are the file’s note types.
14. Centers for Medicare & Medicaid Services and the National Center for Health Statistics. ICD-10-CM Official Guidelines for Coding and Reporting, FY 2027 (Section I.C, chapter-specific guidelines: I.C.9.d, I.C.13.a and b, I.C.16.a and e, I.C.17, I.C.18.d, I.C.19.a, I.C.21.c.7 and I.C.21.c.17). Checked October 26, 2026.
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    “The neurologic deficits caused by cerebrovascular disease may be present from the onset or may arise at any time after the onset of the condition classifiable to categories I60-I67.”; “For ambidextrous patients, the default should be dominant.”; “If the left side is affected, the default is non-dominant.”; “If the right side is affected, the default is dominant.”; “Codes from category I69 may be assigned on a health care record with codes from I60-I67, if the patient has a current cerebrovascular disease and deficits from an old cerebrovascular disease.”; “Codes from category I69 should not be assigned if the patient does not have neurologic deficits.”; “Most of the codes within Chapter 13 have site and laterality designations.”; “Any current, acute injury should be coded to the appropriate injury code from chapter 19. Chronic or recurrent conditions should generally be coded with a code from chapter 13.”; “Chapter 16 codes may be used throughout the life of the patient if the condition is still present.”; “are for use for a child or adult who was premature or had a low birth weight as a newborn and this is affecting the patient’s current health status.”; “Codes from Chapter 17 may be used throughout the life of the patient.”; “When a malformation/deformation, chromosomal abnormality, or genetic disorder does not have a unique code assignment, assign additional code(s) for any manifestations that may be present.”; “Code R29.6, Repeated falls, is for use for encounters when a patient has recently fallen and the reason for the fall is being investigated.”; “Code Z91.81, History of falling, is for use when a patient has fallen in the past and is at risk for future falls. When appropriate, both codes R29.6 and Z91.81 may be assigned together.”; “While the patient may be seen by a new or different provider over the course of treatment for an injury, assignment of the 7th character is based on whether the patient is undergoing active treatment and not whether the provider is seeing the patient for the first time.”; “7th character “D” subsequent encounter is used for encounters after the patient has completed active treatment of the condition and is receiving routine care for the condition during the healing or recovery phase.”; “For example, for aftercare of an injury, assign the acute injury code with the 7th character “D” (subsequent encounter).”; “Aftercare visit codes cover situations when the initial treatment of a disease has been performed and the patient requires continued care during the healing or recovery phase, or for the long-term consequences of the disease.”; “For example, a patient who lives alone may suffer an acute injury temporarily impacting their ability to perform routine activities of daily living. When documented as such, this would support assignment of code Z60.2, Problems related to living alone.”. The prematurity passage is I.C.16.e, on codes from category P07.
15. American Physical Therapy Association. Diagnosis By Physical Therapists (House of Delegates policy, page dated September 8, 2026). “HOD P07-26-29-16: Physical therapists shall establish a diagnosis for each patient/client.”. Checked October 26, 2026.
16. American Speech-Language-Hearing Association. Scope of Practice in Speech-Language Pathology (ASHA policy document, approved by the Board of Directors February 4, 2016). “Speech-language pathologists have expertise in the differential diagnosis of disorders of communication and swallowing.”; “Competent SLPs can diagnose communication and swallowing disorders but do not differentially diagnose medical conditions.”. Checked October 26, 2026.
17. American Occupational Therapy Association. ICD-10 codes: Diagnosis coding resources (Coding and Billing Resources; public part of the page, read in a browser). Checked October 26, 2026.
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    “With the transition to PDPM, PDGM, and impact of diagnosis conditions on the Merit-based Incentive Payment System (MIPS), it is more important than ever to use ICD-10-CM accurately to code medical and treatment diagnoses to the highest level of specificity.”; “The following resources are available to help occupational therapists use ICD-10-CM appropriately.”.
18. American Speech-Language-Hearing Association. ICD-10-CM Coding FAQs for Audiologists and SLPs (ASHA coding guidance). Checked October 26, 2026.
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    “Audiologists and speech-language pathologists (SLPs) are responsible for verifying coding and billing policies with their specific payers.”; “There are no ICD-10-CM codes to reflect a normal result. Instead, the signs and symptoms, chief complaint, or reason for the encounter should be reported as the primary diagnosis.”; “An evaluation to "rule out" a condition is not recognized as a coding convention and should not be used.”; “Generally, audiologists and SLPs should use the ICD-10-CM diagnosis code for the speech, language, swallowing, vestibular, and/or hearing disorder that they are evaluating or treating (i.e., primary or treating diagnosis) as their first-listed diagnosis.”; “The second-listed diagnosis—sometimes referred to as the secondary or medical diagnosis—is the medical diagnosis that is causing or contributing to the speech, language, swallowing, vestibular, and/or hearing disorder.”; “if your payer or facility requests that you list the medical diagnosis as the first-listed diagnosis, and the speech, language, swallowing, vestibular, and/or hearing diagnosis as the second-listed diagnosis, then you should follow that payer’s or facility’s guidance.”; “SLPs are able to diagnose apraxia, and, as such, R48.2 is one of the few codes in the "R" series of codes that can be assigned by an SLP without the patient having a secondary medical condition.”; “The SLP reports as the first-listed diagnosis what the SLP treats—that is, the speech-language disorder, such as R48.8 (other symbolic dysfunction), which captures organic-based language deficits, including pragmatic disorders. The autism diagnosis F84.0 is the secondary diagnosis.”; “There is an Excludes1 note on the R47 family (e.g, dysarthria) indicating that clinicians should not code anything in the R47 family with F84.0 (autism).”; “we advise clinicians to use F80.0 (phonological disorder), along with the autism diagnosis.”.; “Though this is contrary to ASHA’s standard guidance, because of this coding issue, this is the only option for clinicians until the problem is fixed.”
19. Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual, Chapter 5, Part B Outpatient Rehabilitation and CORF/OPT Services (Pub. 100-04, §10.3.2, Exceptions Process, Rev. 3670, effective January 1, 2017). Checked October 26, 2026.
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    “Bill the most relevant diagnosis. As always, when billing for therapy services, the diagnosis code that best relates to the reason for the treatment shall be on the claim, unless there is a compelling reason to report another diagnosis code. For example, when a patient with diabetes is being treated with therapy for gait training due to amputation, the preferred diagnosis is abnormality of gait (which characterizes the treatment).”; “Where it is possible in accordance with State and local laws and the contractors’ local coverage determinations, avoid using vague or general diagnoses.”; “When a claim includes several types of services, or where the physician/NPP must supply the diagnosis, it may not be possible to use the most relevant therapy diagnosis code in the primary position. In that case, the relevant diagnosis code should, if possible, be on the claim in another position.”; “Codes representing the medical condition that caused the treatment are used when there is no code representing the treatment. Complicating conditions are preferably used in non-primary positions on the claim and are billed in the primary position only in the rare circumstance that there is no more relevant code.”. The section was written for the former therapy cap exceptions; the passage on the most relevant diagnosis is stated for all therapy billing.
20. Electronic Code of Federal Regulations. 42 CFR 422.138, Prior authorization (Medicare Advantage; read through the eCFR versioner as of October 22, 2026, the title’s latest issue). Checked October 26, 2026.
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    “Prior authorization processes for coordinated care plans may only be used for one or more the following purposes:”; “To confirm the presence of diagnoses or other medical criteria that are the basis for coverage determinations for the specific item or service; or”; “it may not deny coverage later on the basis of lack of medical necessity”.
21. Centers for Medicare & Medicaid Services. NCCI Policy Manual for Medicare Services, Chapter I, General Correct Coding Policies (revision date January 1, 2026). Checked October 26, 2026.
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    “Additionally, different diagnoses are not adequate criteria for use of modifiers 59 or XE or XS.”; “It is inappropriate to report the best fit HCPCS/CPT code unless it accurately describes the service performed, and all components of the HCPCS/CPT code were performed.”.
22. American Physical Therapy Association. ICD-10 (ICD-10-CM) (APTA coding and billing page). “ICD-10-CM codes are updated annually, and the current year’s codes are to be used for discharges and patient encounters occurring from October 1 of the current year through September 30 of the following year.”. Checked October 26, 2026.
23. Centers for Medicare & Medicaid Services, Medicaid.gov. Early and Periodic Screening, Diagnostic, and Treatment (Medicaid benefits page, read in a browser). Checked October 26, 2026.
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    “The Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit provides comprehensive and preventive health care services for children under age 21 who are enrolled in Medicaid.”; “States are required to provide any additional 1905(a) services that are coverable under the Federal Medicaid program and found to be medically necessary to treat, correct, or reduce illnesses and conditions discovered regardless of whether the service is covered in a state's Medicaid plan.”; “It is the responsibility of states to determine medical necessity on a case-by-case basis.”.
24. Electronic Code of Federal Regulations. 34 CFR 303.21, Infant or toddler with a disability (IDEA Part C) and 34 CFR 300.8, Child with a disability (IDEA Part B; both read through the eCFR versioner as of October 22, 2026, the title’s latest issue). Checked October 26, 2026.
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    “Is experiencing a developmental delay, as measured by appropriate diagnostic instruments and procedures, in one or more of the following areas:”; “Has a diagnosed physical or mental condition that— (i) Has a high probability of resulting in developmental delay;”; “Child with a disability means a child evaluated in accordance with §§ 300.304 through 300.311 as having an intellectual disability, a hearing impairment (including deafness), a speech or language impairment,”; “and who, by reason thereof, needs special education and related services.”. The first two passages are from 303.21(a); the last two from 300.8(a)(1).
25. Electronic Code of Federal Regulations. 42 CFR 410.61, Plan of treatment requirements for outpatient rehabilitation services (read through the eCFR versioner as of October 22, 2026, the title’s latest issue; paragraphs (a) to (c)). Checked October 26, 2026.
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    “Outpatient rehabilitation services (including services furnished by a qualified physical or occupational therapist in private practice), must be furnished under a written plan of treatment”; “The plan prescribes the type, amount, frequency, and duration of the physical therapy, occupational therapy, or speech-language pathology services to be furnished to the individual, and indicates the diagnosis and anticipated goals.”.
26. Electronic Code of Federal Regulations. 42 CFR 424.24, Requirements for medical and other health services furnished by providers under Medicare Part B (read through the eCFR versioner as of October 22, 2026, the title’s latest issue; paragraph (c)). Checked October 26, 2026.
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    “The individual needs, or needed, physical therapy, occupational therapy, or speech-language pathology services.”; “The services were furnished under a plan of treatment that meets the requirements of § 410.61 of this chapter.”; “Recertification is required at least every 90 days.”.
27. DrSensory. DrSensory for Therapists (the For Therapists hub). Checked October 26, 2026.
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    “DrSensory is a directory families use free to find occupational therapy, physical therapy and speech therapy clinics”; “The directory lists clinics rather than individual therapists, so one listing covers a whole practice at one address.”; “the therapies you tick decide which condition and service tags you are offered, and ticking 18+ adds the adult ones.”; “DrSensory does not verify clinical quality, and says so on every results page.”.
28. DrSensory. Therapy Clinic Directory Pricing (the pricing page). Checked October 26, 2026.
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    “Or $349.99 a year. Each additional location is $9.99 a month or $99.99 a year.”; “Ages and conditions treated”; “We do not verify clinical quality.”; “Listing is not an endorsement, and we say so publicly on every results page.”. The first passage follows the listing’s monthly price of $29.99; the second is a row of the table of what a claimed listing adds.

Medical disclaimer. This page is for general educational purposes and does not constitute medical advice, diagnosis, or treatment. It is general guidance on running a therapy practice, not legal, compliance, billing or financial advice. Code titles are quoted from the public FY 2027 ICD-10-CM files; CPT codes belong to the American Medical Association and are named here by number only.