Neurology & Pain Management Coding Alert

If carpal tunnel syndrome (CTS) is suspected but not confirmed, neurologists may use signs and symptoms, pain, and other ICD-9 codes to support medically justified testing and arrive at a definitive diagnosis. This approach avoids labeling the patient with an unconfirmed diagnosis, prevents unwarranted procedures and ensures maximum ethical reimbursement for the treating physician. If a definitive diagnosis is reached, however, the most specific ICD-9 code (i.e., 354.0 -- carpal tunnel syndrome) must be reported.

 
CTS is the most frequently diagnosed compression syndrome of the upper extremities and occurs when the median nerve becomes entrapped as it passes through the space formed by the carpal bones and the flexor retinaculum (a band of connective tissue) in the wrist. The syndrome is often associated with work-related repetitive or cumulative trauma but may be caused by fracture, arthritis, tumor, infection, systematic conditions (e.g., obesity, diabetes mellitus, pregnancy, etc.) and others. Patients suffering from CTS most often complain of numbness, paresthesia (a burning or tingling sensation) and pain in the affected hand(s) and wrist(s), which may appear at night.

 
The most common diagnostic tests for CTS are electromyograms (EMG) and nerve conduction studies (NCS). Documentation is essential when billing these tests. Do not use a "rule-out" diagnosis of 354.0 to substantiate medical necessity -- this unfairly labels the patient as suffering from a condition that he or she may not have. Also, insurers do not accept rule-out diagnoses to justify diagnostic testing.
 
If CTS is suspected, the physician should carefully note all signs and symptoms in the medical record, with evidence of associated problems, such as muscular atrophy, dryness and coldness near the wrist and decreased grip strength. If, after this initial evaluation, the neurologist still suspects CTS, an EMG or NCS may be ordered. Common acceptable diagnoses include 719.44 (pain in joint, hand), 726.4 (enthesopathy of wrist and carpus), 782.0 (disturbance of skin sensation) and 782.3 (edema), says Annette Grady, CPC, CPC-H, who works with three neurology group practices and is the coding and reimbursement coordinator for the Bone & Joint Center in Bismark, N.D.
 
If they are present and substantiated, the neurologist may also report disease and injury diagnoses. For example, arthritis may cause swelling and pressure on the median nerve and develop into CTS. Arthritis codes include 714.0 (rheumatoid arthritis), 715.94 (osteoarthrosis, unspecified whether generalized or localized, hand), 723.4 (brachial neuritis or radiculitis NOS), 727.04 (radial styloid tenosynovitis), 727.41 (ganglion of joint) and 728.6 (contracture of palmar fascia). Injury codes include 955.1 (injury to peripheral nerve[s] of shoulder girdle and upper limb, median nerve) and 955.2 (... ulnar nerve).
 
"The more information you can provide, the less likely the insurer is to reject the claim," Grady says. "If they are present, we usually code up to four diagnoses or symptoms."
 
Neil Busis, MD, chief of the division of neurology and director of the neurodiagnostic laboratory at the University of Pittsburgh Medical Center at Shadyside, and clinical associate professor in the department of neurology, University of Pittsburgh School of Medicine, cautions neurologists to remember that the purpose of providing additional diagnoses is not merely to justify billing diagnostic procedures -- which is fraudulent -- but to establish medical necessity for the tests performed.
 
Note: Some payers may have a limited list of acceptable diagnoses. Contact the insurer prior to billing claims for diagnostic tests for CTS. This will help prevent subsequent denials.
 
Coding EMG and NCS

 
An EMG is reported according to the number of limbs studied. If the patient complains of CTS symptoms in one hand, use 95860 (needle electromyography, one extremity with or without related paraspinal areas). If the patient presents with symptoms bilaterally, use 95861 (... two extremities ... ). It is not appropriate to append modifier -50 (bilateral procedure) to 95861 because its descriptor specifies "two extremities." These codes include the study, interpretation and report. If only interpretation is performed (e.g., the test is performed in the hospital, using its equipment), append modifier -26 (professional component) to the EMG code.  
 
An NCS may be reported with 95900 (nerve conduction, amplitude and latency/velocity study, each nerve; motor, without F-wave), 95903 (... with F-wave) or 95904 (... sensory or mixed), according to the type of study conducted. According to Busis, testing of the median nerve across the carpal tunnel may consist of combined sensory, mixed and motor with or without F-waves studies. Conventional motor and sensory NCS should be coded separately, not bundled together into a single mixed NCS. If both 95900 and 95903 are performed, but on different nerves, append modifier -59 (distinct procedural service) to 95900 to indicate that it should not be bundled into 95903 because it was performed at a different location.
 
NCS codes are billed by units. Report only one code for multiple sites on the same nerve. When the stimulating and recording electrodes are moved to different locations, coding for multiple units is correct, Busis says. Do not append modifier -51 (multiple procedures) to subsequent codes. Some carriers may limit the number of NCS that may be performed during a given period. Contact your individual carrier for its guidelines.

 
Any separately identifiable E/M service, including consultation services, provided on the same day as a diagnostic test may be reported separately. As with an EMG, codes for NCS include the study, interpretation and report. If only the professional component is performed, modifier -26 should be appended.
 
Note: For more information on billing consultations, see "Tips and Guidelines for Successfully Billing Consults" in this issue.
 
For example, a patient presents to his or her primary care physician (PCP) with a complaint of numbness and stinging in both wrists and hands. The PCP will likely use signs and symptoms diagnoses to justify the visit, says Daniel Hemker, a neurology specialist and president of Advantage Billing, a third-party biller in Tinley Park, Ill. The PCP requests a consult from the neurologist. The neurologist examines the patient, checking for (and finding) positive Phalen's (reproduction of symptoms with forced flexion and extension of the wrist) and Tinel (eliciting paresthesias by tapping the median nerve) signs, and documents the patient's complaint and symptoms. Suspecting CTS, the neurologist performs multiple NCS without F-waves and an EMG on each limb, using equipment provided by the local hospital. This is coded:
 
9924x -- office consultation for a new or established   patient
95900-26 x 2
95861-26.

 
In a second example, the same patient presents with symptoms in the left wrist and hand only, and the neurologist performs NCS, both with and without F-waves (at different locations), in the office. This is coded:

9924x
95903
95900-59.

Note: According to Busis, NCS is the preferred method to diagnose CTS, although NCS and EMG are usually performed together because they provide complementary information.
 
In either case, diagnoses of pain, disturbance of sensation and, if present, fluid retention -- along with documentation of the positive Phalen's and Tinel signs -- provide medical necessity for the test. These diagnoses may be used even if the PCP reported the same codes during the patient's initial visit, Hemker says.
 
A diagnosis of 354.0 should not be used until testing has shown CTS to be the definitive diagnosis. If test results show that CTS is not present, the signs and symptoms codes and other documentation will still support medical necessity and ensure reimbursement. Only if the tests show inconclusive results that make a final diagnosis impossible should the neurologist perform more tests. If CTS is present, it must be used as the final diagnosis and no further testing is warranted.