Neurology & Pain Management Coding Alert

Report signs and symptoms first and respect guidelines to get claims paid

Carpal tunnel syndrome (CTS) is a common neurological ailment, and you can't afford to lose out on claims for your CTS patients. To increase your coding success, you'll want to apply modifier -25 consistently with E/M services and same-day testing, as well as support your claims with proper diagnosis coding.

The Patient: Pat is a 67-year-old retired office worker. For several months, she has had pain and tightness in both wrists. She also sometimes has loss of sensation and coldness in her hands. Her primary-care physician has requested a consultation with the neurologist for a possible diagnosis of CTS.

Report an E/M Service for Initial Visit 

You should begin by reporting an E/M service for the patient's first visit, during which the neurologist will examine the patient and determine if her condition warrants further testing, such as nerve conduction studies and electromyography, says 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.
 
In most cases, as in this one, the initial visit will come at the request of another physician. Therefore, you should choose an appropriate consultation code, such as 99243 (Office consultation for a new or established patient ...) or 99244, as supported by the neurologist's documentation.

Turn to -25 for Same-Day Testing, E/M

If, following the E/M service, the neurologist decides to conduct further diagnostic testing on the same day, you must be sure to append modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to any E/M code you claim. This alerts the payer that the E/M service the neurologist provided was above and beyond any inherent E/M component included as a part of the test procedure(s), says Brenda W. Messick, CPC, a coding specialist in Atlanta.
 
For example, the neurologist provides a level-three E/M service and determines that Pat likely has CTS. Not wishing to ask the patient to return at a later date for testing, the physician decides to perform nerve conduction studies (NCS) immediately.
 
To be paid for both the NCS and the E/M service, you should report the appropriate NCS code (for example, 95900, Nerve conduction, amplitude and latency/velocity study, each nerve; motor, without F-wave study) and 99243-25.
 
Don't report "incidental" E/M: If the neurologist schedules a later visit for testing and provides only a cursory E/M service at the time of testing, you cannot report a separate E/M service at that time.

Use Signs and Symptoms to Support E/M, Testing

During the initial visit, the neurologist may suspect a diagnosis of CTS (ICD-9 code 354.0), but until he has confirmed the diagnosis, you should rely on signs and symptoms to justify medical necessity for any services the physician provides.
 
Do not use a "rule-out" diagnosis of 354.0. This approach avoids labeling the patient with an unconfirmed diagnosis while still allowing for reimbursement for the physician even if testing cannot establish a definitive diagnosis, says Darren Carter, MD, president of Provistas Inc. in New York City.
 
Common acceptable signs and symptoms for CTS (all of which Pat exhibits) include 719.44 (Pain in joint, hand), 726.4 (Enthesopathy of wrist and carpus), 782.0 (Disturbance of skin sensation) and 782.3 (Edema).
 
If testing reveals a definitive diagnosis of CTS, you should report 354.0 with the testing and E/M codes and list the signs and symptoms as secondary diagnoses.

Pay Attention to Descriptors for Testing

You should report NCS using 95900, 95903 (... motor, with F-wave) or 95904 (... sensory), according to the type of study the neurologist conducts. The neurologist may provide a combination of all these tests when attempting to confirm a CTS diagnosis.
 
When coding for NCS, report only one code for multiple readings on the same nerve. If the neurologist moves both the stimulating and recording electrodes to different locations on the same nerve, however, you may code for multiple units. Alternatively, you may reference the AMA's list of nerves that constitute separately billable units of NCS, as published in the April 2003 CPT Assistant, to determine the correct units of service, Busis says.
 
Electromyography (EMG) often accompanies NCS when diagnosing CTS. You should report EMG according to the number of limbs the neurologist studies.
 
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 with or without related paraspinal areas).
 
Example: Pat displays symptoms consistent with bilateral CTS. The neurologist provides two motor nerve conduction studies with F-wave, two sensory studies, and one mixed study. In this case, you should report 95903 x 2 and 95904 x 3.
 
Don't forget -26: If the physician tests the patient in the hospital or uses equipment he does not own, be sure to append modifier -26 (Professional component) to the testing codes.