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Anesthesia Coding Alert

A Prescription for Coding Neurogenic Pain

Published on Sat Jun 01, 2002

Neurogenic pain results from damage to the peripheral nerves or the central nervous system. Patients often experience searing, chronic pain associated with conditions like trigeminal neuralgia and postherpetic neuralgia. Neurogenic pain can be notoriously difficult to treat due in part to the patient's sensitivity to touch and other stimuli over diffuse regions. Nonetheless, a number of treatment options may be performed by a pain management specialist. Understanding what is typically involved in diagnosing and treating these disorders, and how to code and bill for treatment, can help in obtaining appropriate reimbursement.

Factors in Diagnosing Neurogenic Pain

As with the description of many forms of chronic pain, most carriers' local medical review policies (LMRPs) define neurogenic pain as a condition present continuously or intermittently for six months or more, or extending two to three months beyond the expected recovery time for postsurgical patients. Mary Jo Marcely, CPC, senior vice president of NAPA Management Services, an anesthesia and pain management consulting firm in New York, says that in diagnosing chronic pain, the physician must thoroughly evaluate the patient. "Two components of the E/M service history and examination are especially crucial. In most situations, a detailed or comprehensive level of history and examination (level three or four) is appropriate for the chronic-pain patient," she says.

The correct E/M code also depends on the site of service. For example, if the physician performed these services for a new patient in an office or other outpatient setting, he or she may choose to use E/M codes 99203 or 99204 (depending on the level of history, evaluation and medical decision-making).

Diagnosis includes assessing the location and duration of the pain and circumstances surrounding the onset of the condition (including potential medication interactions). Further, the effect of the pain on physical and psychosocial function should be investigated because symptoms associated with chronic neurogenic pain also include sleeplessness and depression. Many physicians also will perform a thorough neurological examination and order neurophysiological studies to assist in their diagnosis.

Common diagnosis codes for neurogenic pain include:

  • 053.10 Herpes zoster, with unspecified nervous system complication
  • 053.12 postherpetic trigeminal neuralgia
  • 053.13 postherpetic polyneuropathy
  • 053.19 other
  • 350.1 Trigeminal neuralgia (tic douloureux, trigeminal neuralgia NOS and trifacial neuralgia)

    Trigeminal neuralgia involves a facial nerve disorder but also includes disorders of the fifth cranial nerve. Kelly Dennis, CPC, president of Perfect Office Solutions in Leesburg, Fla., and president of the Florida Anesthesia Administrators Association, says, "Postherpetic trigeminal neuralgia differs from trigeminal neuralgia in that it is defined as severe oral or nasal pain following a herpes zoster infection (shingles). Postherpetic neuropathy refers to multiple areas of pain. It is important for pain management coders to recognize the distinction between these diagnoses."

    Diagnosis,Efficacy and Medical Necessity

    Unlike other chronic pain conditions, neurogenic disorders rarely are treated with traditional physical therapy methods. Even the slightest sensory stimulation can cause the patient extreme pain, manifesting as hyperesthesia (extreme sensitivity to stimulation), hyperalgesia (increasing pain to normally painful stimuli), or allodynia (pain due to normally nonpainful stimuli).

    The most common conservative therapies involve drug administration. These usually include antidepressants, such as amitriptyline (J1320), which is effective for postherpetic neurogenic pain but less effective with trigeminal neuralgia; antiepileptics, such as carbamazepine (J3490) and phenytoin (J1165); and antiarrhythmics, such as mexiletine (J3490).

    Dennis says, "Coders need to be especially careful to code to the highest level of specificity. There are numerous treatment options for these conditions, and treatment methods that seem similar to one another may not be applicable for the particular diagnosis."

    Patients with trigeminal nerve disorders (350.1-350.9) and postherpetic neuralgia (053.12, 053.19) may benefit from therapeutic injections in the tendon sheath, ligament or ganglion cyst (20550). Depending on the carrier's guidelines, the physician also may be entitled to reimbursement for the anesthetic agent.

    Other common treatment for these conditions involves peripheral nerve blocks, epidural injections or intrathecal (subarachnoid injections) containing anesthetic, antispasmodic, opioids or steroids. Dennis says that an epidural catheter usually is not left in place for these blocks. "A common coding scenario for the injection would include 62310 (Injection, single [not via indwelling catheter], not including neurolytic substances, with or without contrast [for either localization or epidurography], of diagnostic or therapeutic substance[s] epidural or subarachnoid; cervical or thoracic) or 62311 ( lumbar, sacral [caudal]), depending on the injection site," Dennis suggests.

    Intercostal nerve block and neurolysis may be performed for patients diagnosed with herpes zoster with unspecified nervous system complication (053.10) and postherpetic neuralgia (053.12). The corresponding codes for the nerve block procedures are 64420* (Injection, anesthetic agent; intercostal nerve, single) and 64421* ( intercostal nerves, multiple, regional block). Fluoroscopy also could be included under 76005 (Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures [epidural, transforaminal epidural, subarachnoid, paraver-tebral facet joint, paravertebral facet joint nerve or sacroiliac joint], including neurolytic agent destruction).

    AdminiStar Federal's LMRP states that intercostal nerve blocks should be done prior to intercostal neurolysis. If the block fails to provide relief, there is no need to continue to neurolysis. Marcely advises coders that if neurolysis of an intercostal nerve is performed (64620, Destruction by neurolytic agent, intercostal nerve), do not use 64420 and 64421 in addition to 64620. "AdminiStar's LMRP also notes that when more than one intercostal neurolysis is performed, modifier -51 (Multiple procedures) should be appended to CPT code 64620 on a separate line for each procedure," Marcely says.

    Note that for intercostal nerve blocks and neurolysis, most LMRPS require that the medical record strictly document the presence of radicular pain and the neuropathic diagnosis treated, a detailed pain history, and the failure of conservative measures to successfully treat the chronic pain.

    Other Treatment Modalities

    When other pain management therapies have failed, the patient may be a candidate for surgical procedures.

    These include microvascular decompression and gamma knife radiosurgery. The surgical codes for these procedures include the following:

  • 61450 Craniectomy, subtemporal, for section, compression, or decompression of sensory root of gasserian ganglion
  • 61458 Craniectomy, suboccipital; for exploration or decompression of cranial nerves
  • 61793 Stereotactic radiosurgery (particle beam, gamma ray or linear accelerator), one or more sessions.

    "Traditionally, these surgical procedures are performed by a neurosurgeon. More and more, surgeons are turning to interventional pain management providers to help manage their patients' postoperative care," Marcely says. "It certainly is beneficial to coders and billers to recognize that this coordination of care is the trend and to be familiar with the reimbursement issues associated with this trend."

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