Internal Medicine Coding Alert

Verify evidence of previous treatments for successful claims.

If you're coding for a patient's carpal tunnel syndrome (CTS) injection, double check for previous, less invasive CTS treatments before getting too far with your claim.

Reason: If the physician administers an injection during the patient's initial visit for CTS, you could be facing a denial. Some payers allow CTS injection therapy only when other treatments have failed.

Check out these FAQs to make each CTS coding scenario a snap.

Should the Physician Try Other Treatments Before 20526?

Yes. The internist would likely try less invasive treatments before resorting to CTS injection (20526, Injection, therapeutic [e.g. local anesthetic, corticosteroid], carpal tunnel), confirms Marvel J. Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, owner of MJH

Consulting in Denver. These treatments might include, but are not limited to:

• splinting (or bracing)
• medication (non-streroidal anti-inflammatory)
• occupational therapy.

If the patient's symptoms don't improve after these attempts, the physician may then proceed with a corticosteroid injection of the carpal tunnel, Hammer says.

Caveat: Check with the payer if you are unsure of its "previous treatment" requirements. Even evidence of previous treatments might not be enough to convince some insurers, says Jacqui Jones, a physician office manager in Klamath Falls, Ore.

"We have had a couple of contracted HMOs [health maintenance organizations] impose conservative nonsurgical treatment -- even with previous treatment and positive nerve conduction velocities ordered by another physician," says Jones.

What Diagnoses Support Carpal Tunnel?

Patients that become candidates for CTS injections may present initially with "complaints of progressively worse numbness and tingling in their hand and wrist, particularly the thumb, index, and middle finger," Hammer explains.

As the CTS symptoms worsen, the patient might experience piercing, sharp pain in the wrist, potentially radiating into the affected arm (719.43 Pain in joint, forearm or 729.5 Pain in limb). The patient's symptoms are usually worse at night, and the patient may also complain of burning sensation in the hand or decreased grip strength (728.87 Muscle weakness).

Documentation clues: For a patient with CTS, the internist may document that the patient has one or more of the following: a positive Tinel's sign (lightly tapping over the median nerve at the patient's wrist reproduces the tingling sensation in the hand) a positive Phalen's maneuver (wrist flexion test in that the patient's paresthesia symptoms are reproduced within 30 seconds to 1 minute after the patient holds their wrist in a maximally flexed position).

What Documentation Helps Support 20526?

Most coders agree that some documentation indicating previous attempts to treat the injury will only help a 20526 claim.

"Best practice documentation of procedures should include the patient's response to previous [CTS] treatments. Even though the CPT® code for carpal tunnel injection falls in the musculoskeletal surgery section of the codebook, only a few payers or providers view this injection as a 'surgery,'" Hammer notes.

A solid 20526 claim should indicate all methods of "non-operative" treatment that have been tried prior to the decision that surgery was needed, experts say. If the payer needs additional information at that point, the coder can submit office notes or any other information to support medical necessity.

Example: Operative notes for a 20526 claim include the following phrases:

• "Nighttime wrist splint therapy began 11/22/10."
• "Weekly PT sessions and strength and stretching regimen began 9/31/10."
• "Steroidal therapy began 11/22/10."