Anesthesia Coding Alert

Millions of Americans suffer chronic pain due to fibromyalgia, reflex sympathetic dystrophy (RSD), unsuccessful back surgery and other conditions. When basic pain-relief treatments such as ibuprofen or other pain medications fail, patients are often referred to a pain management specialist for more advanced treatments. As more of these patients enter pain management care, pain management practitioners and coders wonder what services for these patients will be covered and under what conditions.
 
"We treat fibromyalgia patients all the time," says Kim McDougald, billing supervisor for the physician group West Florida Anesthesia and Pain Management in Spring Hill. The practice began focusing solely on pain management in January 2002. Although McDougald and other coders say that pain management treatment has come a long way in the last few years, many feel it still has far to go.

Proper Diagnosis

The patient's original diagnosis is crucial to correct coding and fair reimbursement. The referring physician and pain management physician often must work together to gain provider approval for treatment of the pain diagnosis.
 
Most patients with fibromyalgia that West Florida Anesthesia and Pain Management treats are diagnosed with ICD-9 729.1 (myalgia and myositis, unspecified), McDougald says. Because these patients may also experience severe muscle spasms, another fairly common diagnosis code is 728.85 (spasm of muscle). Code ICD-9 726.0 (adhesive capsulitis of shoulder) is also used occasionally, although she says they don't treat very many patients for frozen shoulder.

Chronic-Pain Treatment Options

Treatment of chronic-pain patients varies based on the individual's circumstances. McDougald and Scott Groudine, MD, an anesthesiologist in Albany, N.Y., say that five common treatments are:
 
1. Trigger point injections (TPIs) (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). This is the most frequent treatment for chronic-pain patients, and these two codes for TPIs are new for CPT Codes 2002. The descriptor for the code formerly used for TPIs (20550*, injection; tendon sheath, ligament, ganglion cyst) no longer includes "trigger point" in the definition, so it no longer applies to these treatments. Codes for TPIs are the only procedure codes that some carriers cover for chronic-pain patients, McDougald says.
 
2. Epidural steroid injections (ESIs) (62310, injection, single [not via indwelling catheter], not including neurolytic substances, with or without contrast [for either localization or epidurography], of diagnostic or therapeutic substance[s] [including anesthetic, antispasmodic, opioid, steroid, other solution], epidural or subarachnoid; cervical or thoracic; or 62311, lumbar, sacral [caudal]). ESIs can be fairly common for chronic-pain treatment. McDougald says that her group frequently uses ESIs to treat lumbar radiculopathy.
 
3. Intercostal nerve injections (64420*, injection, anesthetic agent; intercostal nerve, single; 64421, intercostal nerves, multiple, regional block; or 64620, destruction by neurolytic agent, intercostal nerve). Code 64620 is for procedures using neurolytic agents that kill the nerve; 64421* is used when the anesthetic agent relieves pain by temporarily putting the nerve to sleep. "Neurolytics such as alcohol, phenol or some other permanent destructive agent result in permanent nerve injury," Groudine explains. "In other words, the area is forever numb. This is a more dangerous procedure than 64421* because you can irreversibly injure structures that are important. Because of this, 64620 is paid at a higher rate than the temporary blocking of intercostal nerves."
 
4. Treatment of muscle spasms (64612, chemodenervation of muscle[s]; muscle[s] innervated by facial nerve [e.g., for blepharospasm, hemifacial spasm]). McDougald says her group occasionally administers botox for muscle spasms. Code 64612 is for the procedure itself, and J0585 (botulinum toxin type A, per unit) is for each unit of botox administered.
 
Botox is the only medication used to treat muscle spasms this way, but Groudine says trigger point injections, oral medications such as Flexeril, and physical therapy can also relieve spasms.
 
5. Sacroiliac (SI) joint injections (20605*, arthrocentesis, aspiration and/or injection; intermediate joint, bursa or ganglion cyst [e.g., temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa]; or 20610*, major joint or bursa [e.g., shoulder, hip, knee joint, subacromial bursa]). Many fibromyalgia or other chronic-pain patients receive sacroiliac joint injections when it is determined that the cause of lower back pain is in the sacroiliac joint. Some carriers may also approve SI injections used for diagnostic purposes to rule out the SI joint as the cause of pain. Groudine cautions that fibromyalgia may not be an accepted diagnosis for SI joint injections, so 720.2 (sacroiliitis, not elsewhere classified) or another code approved by your local carrier may be the most appropriate diagnosis. If both sacroiliac joints are injected, the claim would be appended with modifier
-50 (bilateral procedure).
 
Some carriers allow only one procedure at a visit instead of approving multiple different blocks or pain management procedures. The exception to this is administration of multiple trigger point injections during the same sitting, in which case modifier -59 (distinct procedural service) is also used to indicate that more than one procedure was performed. Modifier -25 (significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) can also come into play if the patient has multiple diagnoses and the pain management physician re-evaluates those diagnoses, the patient's medications, and other circumstances.
 
As popular as trigger point injections and similar treatments may be for helping alleviate chronic pain, many physicians believe that the injections should be integrated into a treatment program of systemic pain relief, sleep improvement, physical modalities such as stretching, and education. Being aware of all parts of a patient's plan can help ensure correct coding and adequate reimbursement for the services provided.