Anesthesia Coding Alert

Hint: You can sometimes submit 20526 with a non-CTS diagnosis.

Coders always want the most specific CPT^® code possible for claims – but sometimes the descriptor's details can cause potential roadblocks.

Case in point: Reporting therapeutic injections for patients with the "carpal tunnel" CPT^® injection code - 20526 (Injection, therapeutic [e.g., local anesthetic, corticosteroid], carpal tunnel) - can cause confusion that slows your reimbursement.

Why?  Code 20526's descriptor includes the words "carpal tunnel." Some payers, however, don't expressly require a carpal tunnel syndrome (CTS) diagnosis for 20526, so the diagnosis coding might not automatically lead you to 20526. Also, most payers require proof of more conservative treatment attempts before you report 20526 - regardless of diagnosis code. And reporting bilateral 20526 shots is another can of coding worms.

If you haven't mastered 20526 coding, don't worry. We've got experts to guide you through those tough 20526 coding questions, so you arrive at the right coding decision each time.

Get CTS Diagnosis Before Reporting 20526 – Most of the Time

For most Medicare (and non-Medicare) providers, the patient must have a CTS diagnosis when you report 20526. If your payer contract expressly states that 20526 is for CTS patients only, this simplifies your coding considerably.

Example: Medicare Administrative Contractor (MAC) Novitas only covers the following ICD-10 codes for 20526, reports Cathy Satkus, CPC, coder at Harvard Family Physicians in Tulsa, Ok:

• G56.00 – Carpal tunnel syndrome, unspecified upper limb
• G56.01 – ... right upper limb
• G56.02 – ... left upper limb
• G56.03 – ... bilateral upper limbs.

Translation: If the patient doesn't have a CTS diagnosis, Novitas won't cover 20526. While this is a general coding rule, it does not necessarily apply to every payer.

"The main diagnosis to use for 20526 would usually be G56.00 to G56.03," says Dreama Sloan-Kelly, MD, CCS, president of Dr. Sloan-Kelly Consulting in Shirley, Mass. "However, I encourage all clients to refer to their local Medicare carrier's LCDs [local coverage determinations]. It is a great resource for ICD-10 diagnosis codes that support medical necessity."

For example, Sloan-Kelly points out Noridian's LCD, which doesn't flat-out forbid you from reporting 20526 with a non-CTS diagnosis. In fact, the LCD lists dozens of diagnosis codes that might support medical necessity for the following CPT^®  codes:

• 20526
• 20527 – Injection, enzyme (e.g., collagenase), palmar fascial cord (i.e., Dupuytren's contracture)
• 20550 – Injection(s); single tendon sheath, or ligament, aponeurosis (e.g., plantar "fascia")
• 20551 – Injection(s); single tendon origin/insertion 
• 28899 – Unlisted procedure, foot or toes.

This does not mean that you can report 20526 for any of the ICD-10 codes listed in Noridian's coverage determination; it does, however, mean that the payer has not explicitly forbidden 20526 reporting with a non-CTS diagnosis.

Another instance in which a payer might cover 20526 is when CTS is mild or moderate, reports Catherine Forman, DC, CPC, COSC, CMC, of University Orthopaedic Associates URMC in Rochester, NY.

According to local coverage determination (LCD) L33622, "Injection of a carpal tunnel may be indicated for the patient with mild to moderate symptoms when pharmaceutical and other conservative measures have failed or are not otherwise indicated."

"The first sign of nerve compression is sensory in nature, so mild forms of CTS can be described as hypoesthesia, paresthesia, or dysesthesia," Forman explains. "In these cases, some providers will perform a diagnostic injection of the carpal tunnel. It is appropriate under these circumstances to bill 20526 with a diagnosis from the signs and symptoms chapter, like R20.2 [Paresthesia of skin]," she says.

Best bet: If you're going to file a 20526 claim with a diagnosis other than CTS, tread softly: Check your payer contract, contact a payer rep, and get approval from your supervisor to file this claim. You don't want payers' ears to perk up on these claims; the biggest red flag for 20526 claims is often a lack of a CTS diagnosis.

To check out Noridian's LCD on these injections, go to: https://med.noridianmedicare.com/documents/10546/6990981/Injections+-+Tendon, Ligament, Ganglion+Cyst, Tunnel+Syndromes+and+Morton's+Neuroma+LCD/fae75e02-cbbd-4630-a012-e37dd6360472.

Document Conservative Treatment Efforts on 20526 Claims

In order to properly report 20526, you need recorded evidence of failed previous attempts to alleviate the CTS, confirms Sloan-Kelly. Make sure the patient's medical record reflects these attempts.

"Essentially, clinical documentation must show that more conservative treatments, such as NSAIDS [nonsteroidal anti-inflammatory drugs], have failed or are contraindicated," she explains. "I always encourage all providers to give an explanation for why it failed - so for instance, in regard to NSAID they should document the patient had very little to no pain relief and describe the pain on a scale of 1 to 10 as always.

"If the provider is stating more conservative [CTS] treatments were contraindicated, they again must state why," Sloan-Kelly continues.

Some forms of prior treatment that might allow for 20526 payment include:

• a course of prescribed prednisone or NSAID;
• wearing wrist braces; or
• a course of physical therapy (PT).

Remember, this is not an exhaustive list. There are other forms of CT treatment the provider might employ before opting for 20526. No matter the treatment, be sure to note it in the documentation for your CT patient.