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Anesthesia Coding Alert

350.1 Essentials:

Upgrade Your Neuralgia Coding Toolbox

Published on Wed Jan 28, 2009

Watch out: Coders and physicians may use different terms for same Dx.

Could your anatomy books be wrong? You need to code a peripheral nerve procedure performed by your pain management specialist, but his documentation mentions only the trigeminal nerve, which is a cranial nerve. What's your next step? Clear up the diagnosis and code right every time with these hints.

Note Differences In Physician's/Coding Terms

Medically, the nervous system is divided into two parts -- the central nervous system (CNS), which consists of the brain and spinal cord; and the peripheral nervous system (PNS), which consists of spinal nerves and cranial nerves.

Spinal nerves in the PNS extend from the spinal cord and connect the CNS to the limbs and organs. The 12 cranial nerves of the PNS connect the brain to the periphery. Peripheral nerve disorders can be the result of diseases such as diabetes, infection, and nerve compression, or can arise as the result of an injury. Some people are born with PNS disorders as well.

Stop confusion now: Medical providers often use the term "peripheral nerves" to mean only those nerves extending from spinal nerves. "Cranial nerves," although officially part of the PNS, are typically not documented as "peripheral nerves" by physicians.

Bottom line: Although your physician may not refer to cranial nerves as peripheral nerves. your diagnosis code choice, 350.1 (Trigeminal neuralgia), will still come fromthe ICD-9 subcategory Disorders of the Peripheral Nervous System, which includes the 350 to 359 range of codes.

Stick With 350.1 for Trigeminal Neuralgia

Code 350.1 includes conditions that can affect one or multiple nerves, says Darlene Ogbuagu, CPC, ACS-AN, a coding supervisor for an anesthesiology and surgical team in Chicago.

"Trigeminal neuralgia is one of the neuralgiaconditions treated by pain management providers. The trigeminal nerve, also known as Cranial Nerve V or fifth cranial nerve, is responsible for sensation on the majority of your face," Ogbuagu says.

Trigeminal neuralgia -- also called tic douloureux -- can be due to many different causes, including compression by a blood vessel as the cranial nerve exits the brainstem and multiple sclerosis.

Note Differences Between 350.1 and 729.2

A hasty coder might conclude after receiving poor or non-specific documentation for a diagnosis of facial neuralgia, she should automatically code 350.1.

Coder beware: Using a specific coding choice for documentation of a non-specific condition or symptom could cause denials or a refund request if reviewed by a payer, particularly if the non-specific condition would not support the service rendered.

It is important that the physician differentiate neuropathic pain from trigeminal neuralgia so you can choose the proper code.

For example: Codes 350.1 and 729.2 (Neuralgia,neuritis, and radiculitis, unspecified) are different in that 350.1 is a specific ICD-9 code choice used to report a fifth cranial nerve neuralgia characterized by recurrent episodes of excruciating, electric shock-like stabbing pain in the sensory distribution of the trigeminal nerve, according to Ogbuagu.

Diagnosis code 350.1 excludes "not otherwise specified" (NOS) neuralgia, neuritis, and radiculitis, for which ICD-9 points you to the unspecified diagnosis code choice 729.2. Similarly, the "excludes" instructions under 729.2 list the more anatomically specific diagnosis codes for brachial, cervical, and lumbosacral radiculitis, mononeuritis, and sciatica.

Translation: You would report 729.2 only when the provider has not documented any additional specificity toreport the patient's symptoms or condition more accurately.

Best practice: Documentation of neuralgia, neuritis, or radiculitis should be location specific, so that the ICD-9 code can most accurately describe the patient's condition, states Marianne Wink, RHIT, CPC, ACS-EM, with the University of Rochester Medical Center in Rochester, N.Y.

Treatment of trigeminal neuralgia varies, so your physician should document the cause or characteristic, location, and severity of pain occurrence. He should also document any patient conditions that may be associated with trigeminal neuralgia, such as multiple sclerosis, vascular anomalies, aneurysms, and neoplasms that could support the use of the 350.1 diagnosis code, says Ogbuagu.

Associated Treatment Codes May Gain $$$

You should be aware of common treatment or procedure codes you're likely to encounter following a neuralgia diagnosis. These include medications such as antidepressants or anticonvulsants; oral or topical painkillers; transcutaneous electrical nerve stimulation (TENS); and anesthetic or steroid injections.

Watch for injections performed: If there are pain management injection procedures performed, there may be challenges with payment, Wink says. "Local carrier payment policies for injections will define what is covered in terms of diagnoses." Checking local carrier determinations and third-party payer coverage policies will help you figure out what's covered.

Recognize Peripheral Neuralgia Symptoms

Symptoms of peripheral neuralgia can start gradually and get worse. Symptoms you may see include pain, tingling, burning, muscle weakness, numbness, or sensitivity to touch. Using ICD-9 codes to list a diagnosis of peripheral neuropathy is difficult because the symptoms are variable, Ogbuagu points out. "A neurological exam is required and involves patient and family history, symptoms, work environment, social habits and exposure to toxins," she adds. Prior to making a diagnosis or pharmacological and surgical intervention, physicians may order diagnostic tests such as MRI, EMG, or nerve conduction studies.

Remember that ICD-9 guidelines instruct you that reporting signs or symptoms is appropriate if you don't have a definitive diagnosis documented.

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