Anesthesia Coding Alert

Diagnosis of nerve and ligament disorders, such as neuromas and tarsal tunnel syndrome, begins with an examination. Rob Davey, CPC, coding consultant with Auditing for Compliance and Education Inc. (ACE) of Leawood, Kan., says, There are three elements that comprise an evaluation and management visit history of present illness, problem-focused examination, and medical decision-making. Yet, the documented medical decision-making by the physician is what ultimately determines the level of E/M code. For E/M of conditions like neuromas or tarsal tunnel syndrome, I would expect a level-three (99203) or -four (99204) initial visit code." Code 99203 includes a detailed history, a detailed examination, and medical decision-making of low complexity, while 99204 includes a comprehensive history, a comprehensive examination, and medical decision-making of moderate complexity. Corinne Kauderer, MD, DPM, FAAHP, FACFAOM, FACFAS, a podiatrist in Brooklyn, N.Y., usually uses 99203 for patient visits for neuromas and tarsal tunnel.
 
For Morton's neuroma and intermetatarsal neuroma (355.6, Lesion of plantar nerve; Morton's metatarsalgia, neuralgia, or neuroma), range-of-motion tests or x-rays may be required to rule out arthritis, joint inflammation, or stress factors. Heidi Stout, CPC, CCS-P, coding and reimbursement manager of University Orthopedic Associates in New Brunswick, N.J., says, "Needle electromyography and nerve conduction studies may be performed in diagnosing tarsal tunnel syndrome (355.5). "Some orthopedic practices have physiatrists or other specialists on staff who conduct this testing." CPT 2002 defines needle electromyography procedures with 95860-95872. Nerve conduction study codes are:
 

CPT 95900 Nerve conduction, amplitude and latency/velocity study, each nerve; motor, without F-wave study

CPT 95903 motor, with F-wave study

95904 sensory

CPT 95920 Intraoperative neurophysiology testing, per hour (list separately in addition to code for primary procedure).

CPT 2002 states that 95900, 95903 and 95904 are modifier -51 (Multiple procedures) exempt. These codes should be reported only once when multiple sites on the same nerve are stimulated or recorded.
 
Stout advises coders that the diagnosis must support the medical necessity of testing. Davey says, "It is important for coders and billers to review payer policies carefully. Claims are mainly denied because of an unspecified diagnosis or a diagnosis that is deemed nonmedically necessary. Specificity is crucial use the diagnosis code that best matches the symptoms."

Treating the Conditions

Conservative treatment for all of these conditions usually includes orthoses and physical therapy. For Morton's neuroma and tarsal tunnel syndrome, injection of an anesthetic agent, such as lidocaine, may bring some relief. Stout says that 64450* (Injection, anesthetic agent; other peripheral nerve or branch) is used most frequently in their practice. She also notes that Medicare does not reimburse for the anesthetic agent.
 
According to the American College of Foot and Ankle Surgeons, nonsteroidal anti-inflammatory drugs (e.g., Celebrex 200 mg) and corticosteroid injections can reduce swelling and inflammation. Stout says that other common agents include Celestone (J0702, Injection, betamethasone acetate and betamethasone sodium phosphate, per 3 mg) and methylprednisolone acetate (J1030). Kauderer performs arthrocentesis (20600*, Arthrocentesis, aspiration and/or injection; small joint, bursa or ganglion cyst [e.g., fingers, toes) using Kenalog-10 (J3301, Injection, triamcinolone acetonide, per 10 mg).
 
Billing for these injections may be tricky. Blue Cross and Blue Shield of North Dakota, in its local medical review policy for Colorado, North Dakota, South Dakota, and Wyoming, states:
 
Morton's neuroma is a neuralgia of one or more of the common digital nerves of the feet. Injecting the nerve with a steroid and a local anesthetic is a diagnostic or therapeutic procedure that involves injecting the solution around but not in the nerve. Accordingly, this injection should not be billed as a peripheral nerve injection (64450*). However, the injection involves more discrimination than a simple subcutaneous injection (90782). There is no specific CPT code for this injection. The closest code is CPT code 20550* (Injection; tendon sheath, ligament, trigger points, or ganglion sheath). This carrier recommends its use when you inject the Morton's neuroma.

Because 20550 has been revised in CPT 2002 to exclude trigger-point injections, practices should check with their local Medicare carrier and private insurers to determine the appropriate code, which medications are reimbursable, and any required documentation.

Surgical Treatments

If conservative treatments fail to bring relief, the patient may opt for surgery. Stout and Davey reference three surgical codes that are relevant to these conditions:
 

28030 Neurectomy, intrinsic musculature of foot

28035 Release, tarsal tunnel (posterior tibial nerve decompression)

28080 Excision, interdigital (Morton) neuroma, single, each.

Stout says that anesthetic is administered with these procedures. "Our surgeons usually perform a nerve block, which we code 64450*, appending modifier -47 (Anesthesia by surgeon). In my experience, we have never been paid for the anesthetic procedure. Most carriers bundle the nerve-block code with the surgical code."
 
Sometimes, more than one surgical procedure is performed during the same session. "For these situations, we list both surgeries on the claim, adding modifier -59 (Distinct procedural service) to the code for the procedure which has the lower reimbursement," she says. "Getting reimbursement for both procedures usually requires some work with the carriers. Most carriers will ask for supplemental documentation, such as the surgeon's notes or operative report."