Anesthesia Coding Alert

Coding for the diagnosis and treatment of whiplash is usually pretty straightforward, but there are situations when coders need to take special care, especially if the patient's symptoms persist despite conservative therapy and warrant more extensive and expensive treatment.

For a lot of people, the term "whiplash" might conjure images of a shady lawyer and equally suspect client trying to finagle compensation for alleged injuries. But physicians commonly diagnose patients who have been in an automobile accident with whiplash (847.0). Another term doctors use to describe a whiplash injury is cervical acceleration/deceleration insult.

Whiplash can occur when the force of an automobile collision causes the vehicle occupant's head to whip back and forth (hyperextension/hyperflexion), says Marvel J. Hammer, RN, CPC, CHCO, president of MJH Consulting, a Denver-based anesthesia and pain management coding and consulting firm.

"Whiplash describes the injury to soft tissues in the cervical spine intervertebral discs, muscles, ligaments and nerves," Hammer says. In addition to neck pain, whiplash symptoms include neck tenderness and stiffness, headache, dizziness, nausea, jaw pain, shoulder and/or arm pain, numbness or tingling, blurred vision and, in rare cases, difficulty swallowing. Some patients have cognitive, somatic or psychological conditions, such as memory loss, concentration impairment, nervousness/irritability, sleep disturbances, fatigue or depression. Hammer says that whiplash leads to long-term disability in 10 percent of people injured in auto crashes.

Conservation Treatment Is the First Step

When a patient presents with whiplash symptoms, the physician will provide a thorough exam and will often order neck x-rays to rule out fractures. Once the whiplash diagnosis has been made, conservative treatment may include physical therapy, nonsteroidal anti-inflammatory drugs (NSAIDs) and muscle relaxants. Some patients may also benefit from wearing a soft cervical collar or by using a portable traction device. If conservative treatment fails to result in significant improvement, the physician may order additional diagnostic imaging tests, including computed tomography (CT) scan, magnetic resonance imaging (MRI), and/or bone scan.

Pain management physicians may also administer trigger point injections (TPI) to alleviate pain and tenderness in muscles, such as the trapezius, splenius capitis and levator scapulae. CPT lists two codes for TPI: CPT 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). Hammer says that the difference between the two codes is the number of muscle groups the physician injects, not the number of injections he or she administers. Consequently, you should bill one unit for either of these codes. Because carriers define muscle groups differently, coders and billers should be aware of their carriers' policies.

CPT 2003 lists revised descriptions for TPI codes. The word "group" has been removed from the definitions, signifying that the injections relate to muscle(s) rather than muscle group(s).

Nerve Blocks Administered for Pain Relief

Although a number of therapies exist, physicians may administer nerve blocks both as a diagnostic tool and to provide temporary pain relief. Doctors may inject anesthetics such as lidocaine (J2000) and steroids such as methylprednisolone acetate (J1020) into cervical facet joints, e.g., at C3-4 and C4-5. Code for these procedures with 64470 (Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; cervical or thoracic, single level) and +64472 (... cervical or thoracic, each additional level). Code 64472 is an add-on code, which means you can list it in addition to the primary procedure (64470). You should report fluoroscopic guidance used with the injections as 76005-26 (Fluoro-scopic guidance and localization of needle or catheter tip ... -professional component).

In general, CMS considers facet joint injections to be unilateral procedures. If the physician performs the procedures bilaterally, append modifier -50 (Bilateral procedure) to the CPT code.

Certain factors, such as age, gender and pre-existing conditions like arthritis, can influence the severity and prognosis of whiplash injuries. When the patient does ot respond to more conservative treatments, or if symptoms worsen, the pain management physician may re-evaluate the patient for other disorders. Hammer says that in these instances, you should code these additional diagnoses along with whiplash. For example, the doctor may determine that the presenting symptoms and/or diagnostic testing indicate occipital neuralgia (723.8), cervicalgia (723.1, Pain in cervical spine or neck region) or facet syndrome (724.8, Other symptoms referable to back). These diagnoses may merit greater pain management intervention.

Many carriers' local medical review policies (LMRPs) provide coverage for nerve blocks for treating cervicalgia and occipital neuralgia, among other diagnoses. The LMRP for Blue Cross/Blue Shield of Arkansas outlines submission requirements for occipital nerve blocks. It notes the carrier will reimburse for blocks used diagnostically to confirm the clinical impression of occipital neuralgia and to treat acute and chronic nuchal muscle spasm and headache. You should report such nerve blocks with 64405* (Injection, anesthetic agent; greater occipital nerve).

When Nerve Destruction Is a Recourse

If nerve blocks do not bring the patient long-lasting relief, the physician may consider paravertebral facet joint denervation. The LMRP for Administar Federal, the Medicare Part B carrier for Indiana and Kentucky, states that the medical record of candidates for paravertebral facet joint denervation should reflect the appropriate diagnostic paravertebral facet joint block or medial branch nerve block studies that identify the specific joint level. The record should also indicate that the patient has had significant but not long-lasting pain relief from the joint blocks. If the patient meets these criteria, the physician may use paravertebral facet joint denervation for patients who have back or neck pain following whiplash/post-traumatic injury and to relieve the pain of associated cervicogenic headache.

Administar's LMRP lists the following CPT codes for denervation:
 

The standard of care for these procedures requires fluoroscopic (76005) or CT-guided (76499, Unlisted diagnostic radiologic procedure) imaging. Therefore, some carriers may deny procedures performed without imaging as inappropriate, unreasonable or unnecessary. As with nerve blocks, CMS considers denervation to be a unilateral procedure, and you should attach modifier -50 to 64626 or 64627 if performed bilaterally. You should also document the joint level(s) denervated in the claim.

Physicians may consider surgical intervention in severe cases, although it is rare for whiplash patients. Most often, surgical treatments are an option when diagnostic tests indicate a disruption of an intervertebral disk or a cervical spinal stenosis.

Until automobile manufacturers integrate greater headrest protection in vehicles, whiplash will remain a common source of head and neck injury. With the unfortunate prevalence of injury and the range of treatment modalities for whiplash and related disorders, physicians and coders need to be aware of what is covered and what is not. "Coders and billers should check with the patient's insurance carrier to confirm authorization of services and verify coding/billing subtleties for improved claims processing," Hammer says. "Sometimes, a simple phone call can alleviate a lot of aggravation down the road."