Anesthesia Coding Alert

Knowing how to submit claims correctly can ease your pain

Coding for the diagnosis and treatment of whiplash is usually pretty straightforward, but you sometimes need to take extra care when coding, especially if the patient's symptoms persist despite conservative therapy and warrant more extensive treatment.

Start With Conservative Treatment    

When a patient presents with whiplash symptoms, your pain management specialist will conduct a thorough exam and will often order neck x-rays to rule out fractures.

First steps: Once the pain specialist diagnoses whiplash, he will try conservative treatment such as physical therapy, nonsteroidal anti-inflammatory drugs (NSAIDs), and muscle relaxants. Some patients may also benefit from wearing a soft cervical collar or by using a portable traction device.

If conservative treatment fails, the physician may order additional diagnostic imaging tests. These include:

• CT scans -- 70490 (Computed tomography, soft tissue neck; without contrast material), 70491 (...  with contrast material[s]) and 70492 (... without contrast material followed by contrast material[s] and further sections)

• MRIs -- 70540 (Magnetic resonance [e.g., proton] imaging, orbit, face and neck; without contrast material[s]), 70542 (... with contrast material[s]) and 70543 (... without contrast material[s], followed by contrast material[s] and further sequences)

• Bone scans -- CT, MRI and x-ray tests include basic bone scans. If your physician orders more extensive bone scans for the patient, you might report 78300 (Bone and/or joint imaging; limited area) or 78305  (... multiple areas) instead.
 
Your physician might also administer trigger point injections to relieve the patient's pain and muscle tenderness. Code these procedures with 20552 (Injection[s]; single or multiple trigger point[s], one or two muscle[s]) or 20553 (... single or multiple trigger point[s], three or more muscles).

Caution: The difference between the two codes is the number of muscles the physician injects, not the number of injections he administers, says Marvel J. Hammer, RN, CPC, CHCO, president of MJH Consulting in Denver.  

The updated descriptors "clarified that if it is a different muscle and documented as such that the number of muscles may be counted to determine the difference between 20552 and 20553," adds Julee Shiley, CPC, a South Carolina coding consultant. "If, however, there are multiple injections within the same muscle, this is only to be counted as one trigger point injection, regardless of the amount of injections."

Further explanation: You'll have to use your best judgment in some trigger point cases because CPT does not have "official" definitions to clarify when to use each code. Some coders recommend following guidelines such as "muscles in close proximity with similar function" equal one muscle group (for example, the right elbow flexors are one group, extensors are another group). If your pain specialist injects two muscles near each other with similar function, he is probably treating the same muscle group. 

Watch point: Because of the "muscle group" distinction between codes, you'll report one unit for either 20552 or 20553 for an encounter -- not both codes. Carriers define muscle groups differently, so verify your carrier's policy before submitting claims.

Move to Nerve Blocks for More Pain Relief  

When more conservative treatments for whiplash don't help the patient enough, your physician might administer nerve blocks to help diagnose a patient's condition or provide temporary pain relief.

Your pain specialist might administer anesthetics such as lidocaine and steroids such as methylprednisolone acetate (J1020) into cervical facet joints (such as C3-4 and C4-5). Note: HCPCS deleted its lidocaine-specific code (J2000) in the 2004 edition as bundled into the injection procedure itself, Shiley says, so don't bill it separately.

Code it: Report these nerve blocks with 64470 (Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; cervical or thoracic, single level) and +64472 (... cervical or thoracic, each additional level [list separately in addition to code for primary procedure]).

Because physicians use fluoroscopic guidance to help ensure they inject the correct site, also report 76005 (Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures [epidural, transforaminal epidural, subarachnoid, paravertebral facet joint, paravertebral facet joint nerve or sacroiliac joint], including neurolytic agent destruction). Then append modifier 26 (Professional component) to 76005.
 
Bilateral question: Facet joint injections are usually unilateral procedures. If your physician administers bilateral injections, however, remember to append modifier 50 (Bilateral procedure) to the injection code.

Watch for Add-on Diagnoses

Certain factors -- such as age, gender and pre-existing conditions like arthritis -- can influence the severity and prognosis of whiplash injuries. When the patient does not respond to more conservative treatments or if her symptoms worsen, your physician may re-evaluate her for other disorders.

In these instances, code the additional diagnoses along with whiplash.

Example: Your pain specialist might determine that the patient's presenting symptoms and/or test results indicate occipital neuralgia (723.8, Other syndromes affecting cervical region), cervicalgia (723.1) or facet syndrome (724.8, Other symptoms referable to back). These diagnoses might merit greater pain management intervention (such as cervical epidurals, facet blocks or even referral to surgery).

Coverage check: Many carriers' local coverage determinations (LCDs) and medical necessity policies cover nerve blocks to treat cervicalgia, occipital neuralgia and other diagnoses. For example, the LCD for Blue Cross/Blue Shield of Arkansas outlines submission requirements for occipital nerve blocks. The carrier will reimburse for diagnostic blocks used to confirm the clinical impression of occipital neuralgia and to treat acute and chronic nuchal muscle spasm and headache. Report these types of nerve blocks with 64405 (Injection, anesthetic agent; greater occipital nerve).

Rely on Nerve Destruction as Last Recourse    

If nerve blocks do not bring the patient long-lasting relief, your pain specialist may consider paravertebral facet joint denervation.

Document it: Before taking the patient's treatment to this level, your physician should have thorough documentation of other treatments. The patient's chart should include two important details:

• the appropriate diagnostic paravertebral facet joint block or medial branch nerve block studies that identify the specific joint level

• documentation that the patient had significant -- but not long-lasting -- pain relief from the joint blocks. 

If the patient meets these criteria, your physician may use paravertebral facet joint denervation to treat back or neck pain following whiplash/post-traumatic injury and to relieve the pain of associated cervicogenic headache.

CPT's codes for denervation in these cases include: 

• 64626 -- Destruction by neurolytic agent, paravertebral facet joint nerve; cervical or thoracic, single level

• +64627 -- ... cervical or thoracic, each additional level [list separately in addition to code for primary procedure].

The standard of care for these procedures includes fluoroscopic (76005) or CT-guided (76499, Unlisted diagnostic radiographic procedure) imaging. Because of that, some carriers might deny procedures the physician performs without imaging. 

As with nerve blocks, physicians usually perform chemodenervation as a unilateral procedure. If your specialist performs a bilateral procedure, append modifier 50 and document which joint levels he treated.

Bottom line: With the prevalence of whiplash injury and the range of treatment options for whiplash and related disorders, physicians and coders need to know what carriers cover -- and what they don't.

"Whiplash may be denied for 'third-party coverage' or third-party subrogation because it often results from an auto accident," Shiley says. "It is helpful to confirm which carrier will be responsible for payment."