Anesthesia Coding Alert

The causes of chronic abdominal pain range from the identifiable, such as Crohn's disease, hernias, lesions, hematomas, desmoid tumors and myofascial tears, to the idiopathic, when pain is not related to a specific physiological source. Increasingly, patients with chronic abdominal pain are turning to pain management physicians. Consequently, pain management coders should become familiar with the treatment options associated with chronic abdominal pain and the diagnoses that support their medical necessity.

Diagnosis and treatment of the sources of chronic abdominal pain vary, depending on the severity of symptoms and the patient's response to treatment. Common treatments include nutrition counseling, physical therapy, trigger point injections, nerve blocks and, in more severe cases, intrathecal pain therapy, nerve destruction and surgery. Patients with certain conditions, such as Crohn's disease (555.9), also may experience symptoms of rheumatoid arthritis (714.xx) and require treatments associated with this secondary diagnosis.

Intra-abdominal Pain

Recent studies have suggested that patients suffering from chronic intra-abdominal pain caused by conditions such as Crohn's disease and abdominal adhesions related to previous surgeries benefit not only from treatments to control inflammation but also from nerve blocks.

For Crohn's patients, anti-inflammatory medications include steroids and Azulfidine, which is also called sulfasalazine and salazopyrene. Mary Klein, CPC, coding specialist with Panhandle Medical Services Inc. in Pensacola, Fla., notes that Azulfidine is an oral medication. Since it is not an injectable drug, it does not have a corresponding J code."

According to the local medical review policy (LMRP) for Blue Cross Blue Shield of Kansas, infliximab (J1745) infusion also has demonstrated clinical efficacy in patients with moderate to severe Crohn's disease who have not responded to other treatments. In addition, infliximab can reduce the symptoms of rheumatoid arthritis in patients who have not responded to methotrexate. The LMRP includes the following covered diagnosis codes: 555.0-555.9 (Regional enteritis) and 714.0 (Rheumatoid arthritis). ICD-9 Codes 565.1 (Anal fistula) and 569.81 (Fistula of intestine, excluding rectum and anus) are listed as secondary diagnoses to be used with the codes for Crohn's disease. Klein notes that infliximab is administered by IV during a two-hour period, with the patient monitored during and after administration for any adverse reaction. "Most of the immediate reactions would be of the allergic type. However, the drug has some possible late reactions that the physician may need to monitor over a period of days or weeks."

Klein says the physician should be the one who monitors the patient during and after infusion. Therefore, 90784 (Therapeutic, prophylactic or diagnostic injection [specify material injected]; intravenous) can be used to report the IV administration. Coders, however, should check with the physician and the LMRPs of their insurance carriers regarding a physician's role in monitoring the patient.

If physician supervision is required, 90780 (Intravenous infusion for therapy/diagnosis, administered by physician or under direct supervision of physician; up to one hour) and +90781 ( each additional hour, up to eight [8] hours [list separately in addition to code for primary procedure]) may be more appropriate. Cindy Parman, CPC, CPC-H, principal and co-founder of Coding Strategies Inc. in Atlanta, adds, "The 90780 code would be appropriate for an infusion administered by a nurse, providing that the physician was in the office suite and immediately available to meet the direct-supervision requirements."

If the patient does not respond to more conventional therapies, a pain management specialist may perform trigger point injections or nerve blocks. Injections into painful trigger points may include a local anesthetic such as lidocaine (J2000, Injection, lidocaine HCl, 50cc) or a local anesthetic and corticosteroid (i.e., J1030, Injection, methylprednisolone acetate, 40 mg [Depo-Medrol]).

CPT 2002 lists two codes for trigger point injections: 20552 (Injection; single or multiple trigger point[s], one or two muscle group[s]) and 20553 ( single or multiple trigger point[s], three or more muscle groups). "The introduction of these new codes in CPT 2002 has caused confusion for some pain management coders," says Parman. "Trigger point injections are coded not only by the number of injections delivered. The injections have to be in a different anatomical muscle group to qualify for the higher-level code. For example, three injections in the rectus abdominis area would be considered one muscle group and coded with 20552."

For more extended pain relief, the pain management specialist may perform a nerve block. According to many carriers' LMRPs, numerous diagnosis codes support the medical necessity of nerve blocks. Parman says that coders should ask the physician which nerve block code(s) are most appropriate but suggests that the following codes could apply, depending on the diagnosis code, the anatomical site and the agent(s) used:

 

64420* Injection, anesthetic agent; intercostal nerve, single

64421* intercostal nerves, multiple, regional block

64425* ilioinguinal, iliohypogastric nerves

64450* other peripheral nerve or branch

64520* Injection, anesthetic agent; lumbar or thoracic (paravertebral sympathetic)

64530* celiac plexus, with or without radiologic monitoring.

Klein says 64530 is commonly used for the nerve block of the abdominal region. "The anesthetic agent used is usually Chirocaine (levobupivacaine injection) or Marcaine. There is no J code assigned for these drugs, so coders may need to use Temporary National Code (non-Medicare) S0020. Again, it is best to check with the local Medicare carrier to see what codes it will accept for these drugs."

Abdominal Wall Pain

An often-overlooked source of chronic abdominal pain is the abdominal wall. Common diagnostic techniques, such as a computed tomography (CT) scan, may not immediately distinguish the abdominal wall as the source of pain. Chronic abdominal wall pain is commonly related to cutaneous nerve root irritation or myofascial irritation when there is no finding of an intra-abdominal process (i.e., nausea, vomiting, changes in bowel habits, fever). Abdominal wall pain is usually chronic, nagging and nonprogressive.

It is also characterized by a localized area of trigger point tenderness, which can be exacerbated by tensing of the abdominal muscles. When hernia or structural diseases are excluded, trigger point injections are useful diagnostic and therapeutic tools. In more severe cases, the pain management physician may perform nerve blocks, especially for patients who have generalized pain that may be related to a thoracic or intercostal nerve root. Klein notes that other than the celiac plexus blocks, the physician may perform an intercostal block(s) (64420 for single, 64421 for multiple/regional) or an ilioinguinal/iliohypogastric nerve block (64425) for abdominal wall pain.

Treatment for Unresponsive Abdominal Pain

In severe cases, some patients with chronic abdominal pain may benefit from intrathecal pain therapy. This involves surgically implanting a device within the abdomen that releases a measured dose of pain medication through a catheter at programmed intervals. Implantable pumps are used to treat many chronic intractable pain conditions. You should ask insurance carriers if this treatment modality is covered.

According to Parman, commonly used CPT Codes for the implantation are:

62360 Implantation or replacement of device for intrathecal or epidural drug infusion; subcutaneous reservoir

62361 non-programmable pump

62362 programmable pump, including preparation of pump, with or without programming.

Placement of the pump includes the initial analysis, setup and programming. Codes 62367 (Electronic analysis of programmable, implanted pump for intrathecal or epidural drug infusion [includes evaluation of reservoir status, alarm status, drug prescription status]; without reprogramming) and 62368 ( with reprogramming) are used for follow-up services.

Parman says drugs are separately billable, and, according to some LMRPs, Medicare may cover certain medication for off-label intrathecal use. According to NHIC, a Medicare Part B carrier for California, Maine, Massachusetts, New Hampshire and Vermont, these drugs include clonidine (J0735), bupivacaine (J3490), fentanyl (J3010), sufentanil (J3490) and hydromorphone (J1170).

Other codes associated with implantable infusion pumps include:

A4220 Refill kit for implantable infusion pump

(this is not reimbursed by all payers.)

C1368 Infusion System, On-Q Pain Management System, On-Q Soaker Pain Management System, and Painbuster Pain Management System (effective Aug. 1, 2000). This code is used by the hospital under the outpatient prospective payment system ambulatory payment classification reimbursement methodology.

A more permanent method of abdominal pain control involves nerve destruction. Klein says nerve destruction is coded with 64680 (Destruction by neurolytic agent, celiac plexus, with or without radiologic monitoring) and that the pain management physicians in her region mostly use the radiofrequency method of destruction. She notes that nerves can also be destroyed chemically, using phenol. She cautions coders, however, to ask insurers if this method is reimbursable for chronic abdominal pain management. Surgery also may be necessary for patients with serious chronic pain resulting from hernias or worsening Crohn's disease, for example, when medication no longer can control the symptoms or when the bowel is obstructed.