Neurology & Pain Management Coding Alert

Here's the scenario: You are coding a peripheral nerve procedure performed by your neurologist, but her documentation mentions only the trigeminal nerve -- a type of cranial nerve. Do you know the right diagnosis code? Clear up any confusion and code correctly every time with these inside secrets.

The nervous system is divided into two parts: the central nervous system (or CNS),which consists of the brain and spinal cord; and the peripheral nervous system (or PNS), which consists of spinal nerves and cranial nerves. (See diagram on page 35.)

Spinal nerves in the PNS extend from the spinal cord, connecting the CNS to the limbs and organs. The 12 cranial nerves of the PNS connect the brain to the periphery.Peripheral nerve disorders arise from diseases such as diabetes, infection, and nerve compression. They can also arise as the result of an injury. Some people are born with PNS disorders as well.

End confusion: Your neurologist may use the term -peripheral nerve- to refer only to those nerves extending from spinal nerves. Although -cranial nerves- are technically part of the PNS, physicians do not typically document them as -peripheral nerves.-

Although your physician may not refer to cranial nerves as peripheral nerves, your diagnosis code choice, 350.1 (Trigeminal neuralgia), will still come from the ICD-9 subcategory -Disorders of the Peripheral Nervous System,- which includes the 350 to 359 code range.

Code 350.1 includes conditions that can affect one or multiple divisions or branches of the trigeminal nerve, says Darlene Ogbuagu, CPC, ACS-AN, a coding supervisor for an anesthesiology and surgical team in Chicago.

-Trigeminal neuralgia is one of the neuralgia conditions treated by pain management providers. The trigeminal nerve, also known as -cranial nerve V- or -fifth cranial nerve,- is responsible for sensation on the majority of your face,- Ogbuagu says.

Trigeminal neuralgia -- sometimes known as -tic douloureux- --can be the result of many different causes, including multiple sclerosis and compression by a blood vessel as the cranial nerve exits the brainstem.

Don't rush to conclude that after receiving poor or non-specific documentation for a diagnosis of facial neuralgia, you should automatically code 350.1.

Coder beware: Using a specific coding choice for documentation of a non-specific condition or symptom could cause denials or a refund request if reviewed by a payer, particularly if the non-specific condition would not support the service rendered. It is important that the physician differentiate neuropathic pain from trigeminal neuralgia so you can choose the proper code.

For example: Codes 350.1 and 729.2 (Neuralgia,neuritis, and radiculitis, unspecified) are different in that 350.1 is a specific ICD-9 code choice used to report a fifth cranial nerve neuralgia characterized by recurrent episodes of excruciating, electric shock-like stabbing pain in the sensory distribution of the trigeminal nerve, according to Ogbuagu.

All diagnosis codes in the 350-359 subcategory range,including 350.1, specifically exclude the diagnoses of neuralgia, neuritis, and radiculitis -not otherwise specified- (NOS). The exclusion notice in ICD-9 points you to the unspecified diagnosis code choice 729.2. Similarly, the -excludes- instructions under 729.2 list the more anatomically specific diagnosis codes for brachial, cervical, and lumbosacral radiculitis, mononeuritis, and sciatica.

Translation: You would report 729.2 only when the provider has not documented any additional specificity to report the patient's symptoms or condition more accurately.

Best practice: Documentation of neuralgia, neuritis, or radiculitis should be location-specific, so that the ICD-9 code can most accurately describe the patient's condition, says Teresa Thompson, CPC, CMSCS, CCC, a consultant in Carlsborg, Wash.

Treatment of trigeminal neuralgia varies, so your neurologist should document the cause or characteristic,location, and severity of pain occurrence. She should also document any patient conditions that may be associated with trigeminal neuralgia, such as multiple sclerosis, vascular anomalies, aneurysms, and neoplasms that could support using the 350.1 diagnosis code, says Ogbuagu.

Symptoms of peripheral neuralgia can start gradually and get worse. Symptoms can include pain, tingling, burning, muscle weakness, numbness, or sensitivity to touch. Using ICD-9 codes to list a diagnosis of peripheral neuropathy is difficult because the symptoms are variable,Ogbuagu points out.

-A neurological exam is required and involves patient and family history, symptoms, work environment, social habits, and exposure to toxins,- Ogbuagu adds. Prior to making a diagnosis or pharmacological and surgical intervention, physicians may order diagnostic tests such as MRI, EMG, or nerve conduction studies (NCS). Your neurologist may perform EMG or NCS tests (codes 95860-95864 and 95867-95872 for EMG, codes 95900-95904 for NCS). You should not bill either the tech or profee component, as only a radiologist would be qualified to bill 7xxxx series codes.

Remember that ICD-9 guidelines instruct you that reporting signs or symptoms is appropriate if you don't have a definitive diagnosis documented.

You should be aware of common treatment or procedure codes you-re likely to encounter following a neuralgia diagnosis. These include medications such as antidepressants or anticonvulsants; oral or topical painkillers; transcutaneous electrical nerve stimulation (TENS); and anesthetic or steroid injections.

Watch for injections performed: If a neurologist performs pain management injection procedures, there may be payment challenges, Thompson says. Local carrier payment policies for injections will define what is covered in terms of diagnoses. You should check your local carrier determinations and third-party payer coverage policies to help you find out what's covered.