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). Know RSD Stages Before Coding Them 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 [...]