Anesthesia Coding Alert

Release Reimbursement for Extended Carpal Tunnel Syndrome Treatment

Published on Sun Dec 01, 2002

When reporting extended treatment for carpal tunnel syndrome (CTS), make sure you document the treatment's medical necessity by carefully outlining its progressive nature.

Pain management physicians and their coders can become frustrated when seeking appropriate reimbursement for treating CTS (354.0), even though it is one of the most frequently diagnosed upper-extremity compression syndromes. Medicare and other insurers can be very strict when processing claims for CTS, especially when conservative therapy methods have failed and the patient receives more extensive treatment.

Insurers can be cautious with claims involving treatment for CTS, says Linda Runfola, CPC, a consultant with NAPA Management Services in Syracuse, N.Y. "A diagnosis of CTS in itself is not enough to justify all forms of treatment. The physician must document the medical necessity of treatment performed and demonstrate that previous treatment modalities have failed to alleviate the symptoms of CTS."

CTS occurs when the flexor tendons in the wrist become enlarged, often due to inflammation, and increase pressure in the carpal tunnel. Because the bones and transverse carpal ligament in the carpal tunnel are not able to stretch in response to the increased pressure, they compress the median nerve that also runs through the carpal tunnel. CTS symptoms include burning, tingling numbness in the fingers, especially the thumb and index and middle fingers, difficulty gripping or making a fist, and inability to hold on to objects. Pain associated with CTS often flares at night. Although physicians sometimes label CTS as a repetitive-stress injury (RSI), it can also result from inflammation caused by arthritis, pregnancy, obesity and diabetes.

Review Carrier Policies for Nonsurgical Treatments

In the early stages of CTS, patients are treated with a variety of noninvasive methods, including physical therapy, orthopedic braces that keep the wrist in a neutral position, and anti-inflammatory medications. If the patient fails to respond to these more conservative treatments, the pain management physician may administer injections (e.g., 20605*, Arthrocentesis, aspiration and/or injection; intermediate joint, bursa or ganglion cyst [e.g., temporo-mandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa]) to relieve discomfort.

As part of its review policy, Cahaba Government Benefits Administrators, Medicare's Fiscal Intermediary for Iowa and South Dakota, notes that "injection of a carpal tunnel is indicated for the patient with a mild case of carpal tunnel syndrome if oral NSAIDs and splinting have failed." Its policy lists these covered codes:

20526 Injection, therapeutic (e.g., local anesthetic, corticosteroid), carpal tunnel

20550* Injection; tendon sheath, ligament, ganglion cyst

20551 Injection; tendon origin/insertion.

Many carriers, like Cahaba, will reimburse separately for the cost of the drug the physician uses in these injections.

Carriers may have limits on the number of injections they cover. For example, Cahaba's policy notes that the clinical record must justify the need for more than three injections for any one episode/occurrence. The policy also states that a recurrence may justify a second course of therapy.

Cahaba policy mentions that if you report other nerve and joint space injection codes, such as 20605, with 20550 and 20551, you must submit documentation to support the medical necessity of the procedure as a separate injection. Runfola notes that Upstate Medicare in New York does not include code 354.0 among its covered diagnoses for 20605, yet the carrier may cover it with appropriate documentation.

If the physician injects both wrists to treat CTS, append modifier -50 (Bilateral procedure). Medicare and some private carriers also recognize modifiers -LT (Left side) or -RT (Right side). The carrier should reimburse these injections as independent procedures, which the doctor often provides during different visits.

You may report an E/M code in addition to these injection codes only if the E/M service is significant and separately identifiable from the injection procedure. If this is the case, you should append the E/M code with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service). If the injection is the primary reason for seeing an established patient, you should report only the injection code.

Although it's not covered by Medicare, physicians occasionally use iontophoresis (97033, Application of a modality to one or more areas; iontophoresis, each 15 minutes) to move the medication through the skin into the carpal tunnel. "Medicare doesn't consider iontophoresis an effective modality, even though it is a fairly common technique used by physical therapists," says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, school director and senior instructor for the A+ Career Academy and CRN Institute in Absecon, N.J.

Relieving Pain With Surgery

When nonsurgical treatments fail, the patient may require surgery to reduce the pressure on the median nerve. Although there are different methods to relieve the pressure, the most common involve either open or endoscopic procedures for carpal tunnel release. Open procedures were once the norm, but they required a longer, more painful recovery. Endoscopic release techniques significantly shorten the patient's recovery period.

CPT 2002 lists two codes related to surgical treatment of CTS:

29848 Endoscopy, wrist, surgical, with release of transverse carpal ligament

64721 Neuroplasty and/or transposition; median nerve at carpal tunnel.

Runfola says that most Medicare carriers reimburse both procedures. Of the two procedures, she notes, physicians perform 64721 more often.

Because surgery is the treatment of last resort for CTS patients, Jandroep suggests that physicians obtain preauthorization to determine any coverage limitations. "If surgery is performed, the medical record should state all of the conservative methods that were tried and failed, thus necessitating the surgical approach."

"Coders should be aware of how Medicare and the private insurers they work with process claims for CTS treatment. In addition, make sure that the patient's record includes as much documentation as possible to back up the medical necessity of treatment," Runfola says.