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Effective Documentation with Pelvic Pain Diagnosis in Pregnant Women

Cynthia Neville, PT, DPT, WCS, BCB-PMD, OTR/L, CMDCP, CDP

May 26, 2015

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Question

Can you give us any tips on effective documentation in this area?  Have you had any trouble with insurance reimbursement?

Answer

That is a great question.  I would absolutely focus on the positive tests for pelvic girdle pain as evidence that there is pelvic joint dysfunction, and the root impairment is a problem with load transfer across the pelvis.  We have had no trouble with insurance reimbursement whatsoever.  Going back to the tips, I would focus on the function.  The patient is having pelvic girdle pain that is interfering with her ability to perform her job as a waitress.  Pain is impairing her ability to care for her children at home.  She is having difficulty traveling to and from work because of pelvic girdle pain.  When we focus on function, most often the insurance carriers really understand that it is not just pain.  We are saying this pelvic girdle pain is leading to a functional impairment and here is what it is and here is why we are seeing it.  We are seeing these positive tests and our plan of care is going to be restore the ability of these joints to transfer load, to restore the normal motor control of those important muscles, and to restore those specific functions.  


cynthia neville

Cynthia Neville, PT, DPT, WCS, BCB-PMD, OTR/L, CMDCP, CDP

Dr. Neville is a board-certified Women’s’ Health Clinical Specialist (WCS) and President of her consulting and education firm, Neville Know-How, Inc. She is currently providing clinical patient care as a pelvic health physical therapist and is an Associate Professor of Physical Therapy at Mayo Clinic, Jacksonville, Florida. A highlight of her career was developing the first credentialled Women’s Health Physical Therapy Residency Program in the state of Florida at Brooks Rehabilitation in Jacksonville. She has published several peer-reviewed research articles and textbook chapters. She has been practicing and teaching pelvic health physical therapy courses for over 30 years.


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Editor's Note: Regarding Pennsylvania credits, this course is approved by the PA State Board of Physical Therapy for 1 hour of general and 1 hour of Direct Access CE credit.

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