Anesthesia Coding Alert

Learn the other terms used to denote CRPS I, II in the documentation.

Proper reporting of complex regional pain syndrome (CRPS) requires attention to detail and knowledge of condition specifics. While not physically painful, choosing the correct codes to submit for your patients with CRPS can be complex and frustrating.

To help you cut through the confusion, Anesthesiology Coding Alert asked industry pros for some insight into CRPS. Let the answers to these FAQ guide you through the snags, so you’ll be well-equipped to submit airtight claims the next time one comes your way.

Question: What is CRPS, and how can coders differentiate between CRPS I and CRPS II in encounter notes if it isn’t spelled out?

Answer: CRPS is a chronic pain condition that most often affects a patient’s limb, usually after an injury. Experts believe that CRPS occurs as a result of central or peripheral nervous system dysfunction.

Typically, CRPS is classified into two different types:

• CRPS I: When a patient doesn’t have a confirmed nerve injury.
• CRPS II: When the physician can trace the patient’s pain to an identifiable nerve injury.

“The biggest difference is that CRPS I does not include damage to the nerves. CRPS II involves nerve injury. CRPS I is the most prevalent type (90 percent of all CRPS cases) and is commonly referred to in clinical documentation as reflex sympathetic dystrophy syndrome (RSD). CRPS II is commonly referred to in clinical documentation as causalgia. Coders should look for any references or indications of nerve damage, which would support CRPS II,” explains Toni Elhoms, CCS, CRC, CPC, AHIMA-Approved ICD-10-CM/PCS Trainer, chief executive officer, Alpha Coding Experts, LLC, in the Orlando, Florida area.

Question: What types of treatments and/or procedures are commonly used for patients with CRPS?

Answer: The pain management physician may provide an office evaluation and management (E/M) service and offer prescriptions — for example, anesthetic creams, antidepressants, nonsteroidal anti-inflammatory drugs (NSAIDs), anticonvulsants, corticosteroids, opioids — or one of the following interventions:

• Sympathetic nerve block: 64510 (Injection, anesthetic agent; stellate ganglion (cervical sympathetic)) through 64520 (… lumbar or thoracic (paravertebral sympathetic))
• Epidural steroid injection (ESI): 62320 (Injection(s), of diagnostic or therapeutic substance(s) … including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance) through 62327 (Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) … with imaging guidance (ie, fluoroscopy or CT))
• Spinal cord stimulator: 63650 (Percutaneous implantation of neurostimulator electrode array, epidural) through 63688 (Revision or removal of implanted spinal neurostimulator pulse generator or receiver)
• Physical and mirror therapy: 97110 (Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility) through 97140 (Manual therapy techniques (eg, mobilization/ manipulation, manual lymphatic drainage, manual traction), 1 or more regions, each 15 minutes)
• Biofeedback: 90901 (Biofeedback training by any modality)

Question: Could you provide an example in which the provider diagnoses and treats a patient with CRPS I?

Answer: CC: Patient presents with right upper extremity (RUE) pain.

HPI: A 37-year-old patient presents with right arm pain from the elbow to the wrist. Pain is severe with a 7/10 pain level. Patient describes the pain as burning, continuous, and similar to electrical shock. Past medical history includes traumatic fractures to the right elbow and wrist with no nerve involvement three years ago.

Assessment: Patient exhibits RUE CRPS I due to traumatic elbow and wrist fractures without nerve damage.

Plan: Patient to receive a right cervical sympathetic nerve block to provide pain relief.

CPT^® Code: 64510-RT (Right side)

ICD-10 Code: G90.511 (Complex regional pain syndrome I of right upper limb)

Question 4: Could you provide an example in which the provider diagnoses and treats a patient with CRPS II?

Answer: CC: Patient presents with left lower extremity (LLE) pain.

HPI: A 42-year-old patient presents with left leg pain radiating from the femur to the ankle. Pain is severe with a 9/10 pain level. Patient describes the pain as burning and constant and states his leg tremors and jerks. Past medical history of crushing injury to LLE one year prior with confirmation of nerve damage on nerve conduction testing.

Assessment: Patient exhibits LLE CRPS II due to crush injury with confirmed nerve damage.

Plan: Patient to receive sacral ESI with fluoro to provide pain relief.

CPT^® Code: 62323 (Injection(s), of diagnostic or therapeutic substance(s) … including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (ie, fluoroscopy or CT))

ICD-10 Code: G57.72 (Causalgia of left lower limb)

Pro tip: “If your pain practice is providing chronic pain management, make sure you’re aware of the American Society of Anesthesiologists (ASA) standards and guidelines for pain management. A Statement on Access to Pain Care was developed and approved as of October 18, 2023, to oppose ‘unnecessarily burdensome prior authorization processes.’ This guideline, the Statement on Anesthetic Care During Interventional Pain Procedures for Adults, and more are available at www.asahq.org/standards-and-practice-parameters (word search ‘pain’),” notes Kelly D. Dennis, MBA, ACS-AN, CANPC, CHCA, CPC, CPC-I, president of Perfect Office Solutions in Leesburg, Florida.

For further study: Find these statements at www.asahq.org/standards-and-practice-parameters/statement-on-access-to-pain-care; www.asahq.org/standards-and-practice-parameters/statement-on-anesthetic-care-during-interventional-pain-procedures-for-adults.