Anesthesia Coding Alert

Documentation is the key to success 

When a patient’s carpal tunnel syndrome (CTS) treatment stretches into extended care, don’t let carriers’ strict guidelines stop rightful reimbursement in its tracks. Train your providers to document medical necessity by carefully outlining the condition’s progressive nature. 

Showing Full Diagnosis Starts You Off Right   

ICD-9 only includes one CTS diagnosis: 354.0 (Carpal tunnel syndrome). Having only one code would seem to make your job easier, but carrier policies complicate your situation.

Roadblock: A stand-alone diagnosis of CTS doesn’t justify all forms of treatment in some carriers’ eyes. The ease of proving medical necessity depends partly on the service your physician provides.

“Usually, proving medical necessity of an injection is not as crucial as proving the medical necessity of more invasive surgical procedures,” says Myriam Nieves, CPC, ACS-PM, owner of the consulting firm Precision Medical Systems in Ft. Lauderdale, Fla.

Injection necessity: If your physician plans to administer a pain management injection to treat a patient’s CTS, carriers may require documentation that the patient has changed or avoided activities that cause the CTS symptoms, or that the patient needs to take frequent breaks from repetitive tasks.

Surgical proof: Before giving the go-ahead for open or endoscopic surgery to treat CTS, carriers might require documentation that NSAIDs, splints and physical therapy have failed or are not otherwise indicated. The carrier might also require proof of abnormal neuroelectrodiagnostic test results (such as electromyography [EMG] or nerve conduction studies).

Basic symptom coding: Common CTS symptoms include burning, tingling and numbness in the fingers (especially the median nerve distribution including the thumb, index and middle fingers), difficulty gripping or making a fist, an inability to hold objects, and wrist pain. Use codes such as 719.44 (Pain in joint; hand) and 782.0 (Disturbance of skin sensation), 728.87 (Muscle weakness [generalized]) and/or 719.43 (Pain in joint; forearm) to cover these patient symptoms. (Code 782.0 covers the burning, tingling and numbness patients often have.)

The signs and symptoms associated with CTS sometimes appear as a complication of other conditions. These might include:

• Reflex sympathetic dystrophy -- 337.20 (Reflex sympathetic dystrophy, unspecified) or 337.21 (Reflex sympathetic dystrophy of the upper limb)

• Trigger fingers -- 727.03 (Trigger finger [acquired])

• Nodules in the hands -- 782.2 (Localized superficial swelling, mass or lump)

• DeQuervain’s disease/syndrome -- 727.04 (Radial styloid tenosynovitis)

• Dupuytren’s contractures -- 728.6 (Contracture of palmar fascia).

Inflammation caused by arthritis, pregnancy, obesity, hypothyroidism, repetitive motion disorder (RMD) and diabetes can also lead to CTS, says Tonia Raley, CPC, claims processing manager for Medical Information Systems in Phoenix.

Review Carrier Policies for Nonsurgical Treatments  

Physicians use a variety of noninvasive treatments for patients in the early stages of CTS.

“Depending on the severity of the condition, treatment may be conservative,” Raley says. Initial treatment can include having the patient change activities, wear a soft splint, undergo physical therapy and/or take anti-inflammatory medications.

Next step: If the patient fails to respond to these more conservative treatments, your physician might administer joint injections to relieve the patient’s discomfort, such as 20526 (Injection, therapeutic [e.g., local anesthetic, corticosteroid], carpal tunnel), 20550 (Injection[s]; single  tendon sheath, or ligament, aponeurosis [e.g., plantar “fascia”]) and 20551 (... single tendon origin/insertion).

Watch out: Many providers relied on 20605 (Arthrocentesis, aspiration and/or injection; intermediate joint or bursa [e.g., temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa]) to report a carpal tunnel injection before CPT introduced 20526 a few years ago. Now 20526 is a more accurate code in most circumstances.

Carriers expect physicians to try nonsurgical, conservative treatments first, but most policies don’t outline specific guidelines for when your physician should move to the next treatment level.

“I was only able to find one carrier (Unicare) that required at least four weeks of splinting before the doctor proceeds to injections,” Nieves says. “If surgerywas necessary, the carrier wanted four weeks of splinting followed by four weeks of injections, confirmed by an electrodiagnostic test and verification that the problem was not associated with pregnancy, arthritis or hypothyroidism.”

Medication note: Many carriers will reimburse separately for the cost of the drug your specialist uses during the procedure.

Injections into the carpal tunnel typically include a corticosteroid along with a local anesthetic.

Deal With Multiple Services Correctly

Physicians may administer bilateral carpal tunnel injections if the patient has symptoms in both hands or administer the injections along with another service during the patient’s visit. When that’s the case, be sure to submit the appropriate modifiers with your claim.

Bilateral checkpoint: If your pain management specialist injects both of the patient’s wrists during CTS treatment, you’ll need to report it as a bilateral procedure. You can do this with either modifier 50 (Bilateral procedure) or modifiers LT (Left side) and RT (Right side).

If you report modifier 50, simply append it to the injection code for most carriers. If your carrier prefers modifiers LT and RT, report the injection code as two line items (one with LT and one with RT). Check your carrier’s guidelines to verify its preference.

Additional service: Physicians often perform other services when a patient comes for an injection -- but that doesn’t mean you can always code it separately. You may report an E/M code in addition to the CTS injection codes only if the E/M service is significant and separately identifiable from the injection procedure.

Example: The patient comes to your office for a CTS injection and also complains to the doctor that he has knee pain. Your physician can complete an E/M service to check the knee problem and bill for it.
 
When the additional service qualifies for an E/M code, append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the E/M code.

Caution: If the injection is the primary reason your physician sees the patient, you should only report the injection service.

Example: If the doctor has already decided to administer a CTS injection and wants to evaluate the patient prior to the procedure, you cannot report the evaluation as a separate, billable service.

See Surgery as the Last Resort

When nonsurgical treatments fail, your physician might determine that the patient needs surgery to reduce the pressure on the median nerve.

The most common approaches to relieve the pressure are open or endoscopic procedures for carpal tunnel release. Physicians once opted for open procedures as the norm, but the patient had a longer, more painful recovery. Endoscopic release techniques significantly shorten the patient’s recovery period.

CPT includes two codes related to surgical treatment of CTS:

• 29848 -- Endoscopy, wrist, surgical, with release of transverse carpal ligament (for an endoscopic approach)

• 64721 -- Neuroplasty and/or transposition; median nerve at carpal tunnel (for an open approach).

Because surgery is a last-resort treatment for CTS, many coders recommend that you obtain preauthorization to determine your carrier’s coverage limitations.

“As with any other procedure, always make sure that the patient’s plan covers the service and that there are not any pre-existing conditions that might prevent the claim from being paid” (such as a fractured wrist unrelated to work that caused the problem), Nieves says.

Bottom line: Obtaining rightful reimbursement for long-term CTS treatment is possible, as long as your practitioners document the entire process to prove medical necessity. With complete documentation in place, you can correctly code each treatment to show what the patient has gone through.