Anesthesia Coding Alert

The most common diagnosis code for fibromyalgia is ICD-9 729.1 (Other disorders of soft tissues; myalgia and myositis, unspecified). The definition includes fibro-myositis (inflamed fibromuscular tissue), myalgia and myositis. Fibromyalgia is difficult to diagnose because its symptoms mimic those of other disorders. Franz Ritucci, MD, DABAM, FAEP, director of the American Academy of Ambulatory Care in Orlando, Fla., says that diagnosing fibromyalgia is frustrating for the physician and patient. "The diagnosis is one of exclusion. There is no single lab test that can establish a diagnosis of fibromyalgia; rather, exhaustive testing is performed to rule out other causes of diffuse musculoskeletal pain, such as polymyalgia rheumatica, Parkinson syndrome, or endocrine disorders."
 
In 1990, the American College of Rheumatology (ACR) established guidelines to aid physicians in diagnosing fibromyalgia. These include:

 

a history of widespread pain of three months or longer; widespread pain is defined as pain on both the right and left sides of the body

 

pain to palpation in 11 or more of 18 specified tender points.

Ritucci notes that the locations of tender points are remarkably consistent from patient to patient. "This consistency is helpful in diagnosis."
 
According to James Mallow, MD, an anesthesiologist and pain management physician in Leawood, Kan., other symptoms include sleep disturbance, fatigue, stiffness, skin fold tenderness, and cold intolerance. Mallow also notes that a common misdiagnosis is myofascial syndrome. "The difference is that myofascial syndrome is a local regional problem, whereas fibromyalgia is widespread."

Susan West, RHIT, coding consultant with Auditing for Compliance and Education Inc. (ACE) of Leawood, Kan., reminds coders that the appropriate E/M code depends on three key elements: history, exam and medical decision-making. "For an initial visit, the physician should use the E/M code which best reflects the level of evaluation and management provided," West says. For a patient who presents with symptoms of fibromyalgia, this may mean using a higher-level E/M code, such as 99203 or 99204.
 
If another physician requests an opinion or advice on the patient's evaluation and/or management and a consulting physician performs the E/M, Ritucci says, 99244 (office consultation) might be appropriate. "In this instance, the physician has probably spent 60 minutes face-to-face with the patient and/or the patient's family." Ritucci stresses that physicians should have adequate documentation to substantiate their choice of E/M code.

Extensive diagnostic tests may be performed by the pain management physician. Mallow notes that two of the most useful tests involve measuring the erythrocyte sedimentation rate (ESR) and the level of serum creatine kinase. Codes for these procedures are:

 

82550 Creatine kinases (CK), (CPK); total
 

82552 ... isoenzymes
 

82553 ... MB fraction only
 

82554 ... isoforms
 

85651 Sedimentation rate, erythrocyte; non-automated
 

85652 automated.

A policy bulletin issued by Transamerica Occidental Life Insurance Company, a Medicare Payment Safeguard Administrator, states that ESR is frequently the earliest indicator of disease when other chemical or physical tests are normal. Their list of covered diagnoses includes 729.1. However, ESR is not covered when it is performed for screening or as part of a routine physical examination.
 
Note: Many Medicare Part B carriers do not include 729.1 in their list of covered diagnoses for creatine kinase testing. Coders and billers should check the coverage requirements of their local carriers and private payers before ordering or performing these procedures.
 
Needle electromyography (EMG) (95860-95872) is also often performed to test for fibromyalgia. Mallows says that 75 percent of the patients who meet the ACR criteria for fibromyalgia also meet the criteria for chronic fatigue syndrome (780.71). West says that it is appropriate to list a secondary diagnosis, such as chronic fatigue syndrome, if the documentation supports it.

Practitioners often prescribe nonsteroidal anti-inflammatory drugs and Elavil. Sinemet or Klonopin are used for restless leg syndrome (333.99), another diagnosis associated with fibromyalgia. Ritucci says that about a third of patients are also treated with antidepressants or muscle relaxants that are structurally related to the tricyclic antidepressants.
 
Trigger-point injections (TPI) are used to treat major focal areas of pain. West suggests reporting TPI services with two new codes:

 

20552 Injection; single or multiple trigger point(s), one or two muscle groups
 

20553 single or multiple trigger point(s), three or more muscle groups.

The physician may also bill for the medication if the treatment was performed in his or her office. HCPCS 2002 states that drugs are covered if they meet certain requirements. One requirement is that the drug must be reasonable and necessary in the patient's treatment and administered based on accepted standards of medical practice. A complete listing of the requirements are in HCPCS 2002 Appendix 4: Medicare References.
 
Massage or heat therapy may also be billable. West states that for myofascial release, use 97140 (Manual therapy techniques [e.g., mobilization/manipulation, manual lymphatic drainage, manual traction], one or more regions, each 15 minutes). For other massage therapy, report 97124 (Therapeutic procedure, one or more areas, each 15 minutes; massage, including effleurage, petrissage and/or tapotement [stroking, compression, percussion]).
 
Ethical reimbursement for the diagnosis and treatment of fibromyalgia is based on local medical review policies, which vary by state. These policies often require that the physician maintain documentation supporting the medical necessity of any services provided. Coders should check with their local carrier and private insurers to determine their guidelines for claims submission and reimbursement.