Anesthesia Coding Alert

Reflex sympathetic dystrophy (RSD) is a chronic pain disorder of the sympathetic nervous system. Diagnosis can take years, and treatment can be ever-changing, so coding for RSD can be as complex as the disorder itself.

RSD commonly affects the median and sciatic nerves (337.20, Unspecified RSD; 337.21, RSD of the upper limb; 337.22, RSD of the lower limb; and 337.29, RSD of other specified site). Injury, trauma, surgery, infection, casting and myocardial infarction usually cause RSD. The constant pain of RSD increases because of coexisting conditions such as nerve entrapment (355.9, Mononeuritis of unspecified site), peripheral neuropathies (356.9, Hereditary and idiopathic peripheral neuropathy, unspecified), carpal tunnel syndrome (354.0), and/or tarsal tunnel (355.5) and thoracic outlet syndrome (353.0).

RSD is a three-stage disease process. Although the stages are the same in each patient, their progression varies. Because every patient does not experience all the signs, symptoms and clinical features of RSD, treatment and coding for it can vary. The initial indication for treatment is prolonged pain. Some patients might take oral pain medications for a year or longer without relief before being diagnosed with RSD, says coder Barbara Johnson, CPC, MCP, with Loma Linda University Medical Group in Loma Linda, Calif. Pain is present in all stages of RSD.

Other characteristics of RSD include sensitivity to temperature or light touch, severe (usually a burning-type) pain and skin color changes (generally a loss of color so the skin appears almost white). Swelling and redness of the affected area are common in cases that are vascular in origin, says Franz Ritucci, MD, director of the American Academy of Ambulatory Care in Orlando, Fla. Even something as simple as temperature changes (such as cool air from the refrigerator or freezer sections of supermarkets) can cause extreme pain for RSD patients. These characteristics can have a tremendous effect on the normal lifestyle of patients.

In the second stage of RSD, the affected area becomes blue, cold and painful. Osteoporosis (733.0x) and joint stiffness (719.5x) can develop during this stage.

The third stage of RSD can include wasting of the muscles and tendons, contracture and withering of the affected limb (represented by diagnosis codes such as ICD-9 728.2, Muscular wasting and disuse atrophy, not elsewhere classified). Trish Bukauskas-Vollmer, CPC, owner of the anesthesia and pain management consulting firm TB Consulting in Myrtle Beach, S.C., says an appropriate "late effects" code (905.x, Late effects of musculoskeletal and connective tissue injuries) may also be assigned if RSD follows a fracture, trauma or other injury. "This makes the documentation very explicit and paints the full picture for the insurance company," she explains.

Capture Codes for All Diagnostic Tests

Early diagnosis of RSD is important so treatment can begin as soon as possible. Many anatomical tests are unreliable diagnostic tools because they do not give an accurate and complete picture of the disease. (These include myelograms and CT scans, which are coded based on whether the physician conducts the procedures with, without, or with and without contrast; what body area is scanned; and whether the procedure is unilateral or bilateral. Ranges to consider include 72240-72270 for myelography and 71250-71270, 72125-72132 and more for CT scans.)

"Unfortunately, RSD is a condition of exclusion," Ritucci says. "The physician must rule out infection, hypertrophic scarring, bone fragments, neuromas or other problems before diagnosing the patient with RSD." A three-phase bone scan (78315, Bone and/or joint imaging; three phase study) is one way to diagnose the disease, assess its stage and rule out other problems such as neoplasms or osteomyelitis.

An acetone drop test to demonstrate allodynia (pain from light touch) is one common diagnostic tool for RSD. Alcohol is placed on the affected limb and blown dry. The coldness felt as the alcohol evaporates does not affect most people, but an RSD patient will experience cold hyperalgesia (782.0,Disturbance of skin sensation) during the process.

Physiological tests to diagnose RSD can include diskography (72285 and 72295 for radiological supervision and interpretation of cervical, thoracic, or lumbar treatments; and 62290 and 62291 for the diskography injection), nerve conduction studies (95904), angiograms and bone scans. Tests that measure the interaction between the disease and the patient's body are important to help plan treatment. This helps determine the disease stage and how the patient might respond to treatment, Bukauskas-Vollmer says.

Correct Pain Codes Depend on Treatment

RSD treatment should begin as early as possible and be as aggressive as possible to help alleviate the patient's pain and improve his or her quality of life. Treatment usually consists of several different modalities to determine which works best for the particular patient.

Regional sympathetic blocks can provide immediate pain relief and are often administered soon after the physician makes a diagnosis (or even before the patient is officially diagnosed with RSD). You should report these blocks with the site-specific codes 64505-64530.

How should you code the visit if the doctor administers a sympathetic block during the same visit he or she reaches the RSD diagnosis? Report the appropriate 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). Include the pain or the patient's chief complaint, and then report the appropriate block code with a more specific diagnosis code that the physician determined through the evaluation. Coding guidelines state that separate diagnoses are not necessary, but Bukauskas-Vollmer says some local medical review policies (LMRPs) specify that carriers won't pay for an E/M visit along with another procedure, and using multiple diagnoses overrides those edits so the physician can be reimbursed.

Drug therapy (pain medications) and physical therapy are other common first-line treatments for RSD that continue throughout the syndrome's course. Ritucci says physicians may also use myofascial trigger point/acupuncture injections (20552-20553), hypnosis (90880, Hypnotherapy), and biofeedback (90901, Biofeedback training by any modality; and 90911, Biofeedback training, perineal muscles, anorectal or urethral sphincter, including EMG and/or manometry) in the early stages of the disease. Check local guidelines before reporting these services because carriers may not cover all of them (such as hypnosis or relaxation training).

Whatever modalities the provider chooses, he or she must remember the patient's allodynia when designing an RSD patient's treatment program. Even bubbles from water therapy can produce extreme pain.

If these more conservative treatment regimens fail, transcutaneous electrical stimulators or implantable devices may be considered (spinal cord stimulators, 63650-63688). Ritucci notes that physicians generally approach these options with caution and only after more conservative treatment regimens have failed.

If spinal cord stimulators are the preferred treatment option, two types are available: radiofrequency (external) or implantable pulse generators. Both types are patient-controlled, meaning the patient can control the medication's administration, and both have percutaneous or surgically placed electrodes. Physician preference, patient input, and the patient's health status help determine which generator the provider uses. Patients with pain in a single extremity are better candidates for the implanted pulse generator.

The final treatment approach for RSD involves surgery sympathectomies to excise a portion of the affected nerve. Injecting neurolytic agents into the nerve (64600-64680) has the same effect of destroying the nerve and its ability to sense pain."The biggest problem with treating RSD patients in a pain practice is that by the time the patient gets referred to a pain specialist, their RSD is no longer in the first stage and it is more difficult to treat," Bukauskas-Vollmer says. "Pain specialists would have greater positive outcomes if they were able to treat the patient earlier, even in stage one."