Neurology & Pain Management Coding Alert

Carpal tunnel syndrome (CTS) is the most frequently diagnosed compression syndrome of the upper extremities. CTS responds to treatments ranging from physical therapy to surgical intervention, depending on the severity of the problem. Because extensive treatment options are generally more expensive, insurers insist that physicians initially rely on conservative treatment and progress to more expensive methods. Careful documentation and a complete medical record outlining the progressive nature of the treatment plan are essential to avoiding payment delays and denials.

Begin with a definitive diagnosis. Patients suffering from CTS (354.0) most often complain of numbness, paresthesia (a burning or tingling sensation) and pain either in one hand or wrist (unilateral) or in both hands or wrists (bilateral) that may flare up at night. Other symptoms include muscular atrophy, dryness and coldness near the wrist, and decreased grip strength. The syndrome is often associated with work-related repetitive or cumulative trauma but may be caused by fracture, arthritis, tumor, infection or systematic conditions such as obesity, diabetes mellitus or pregnancy. Electromyograms and nerve conduction studies are the most common diagnostic tests for CTS.
 
Note: Careful documentation of signs and symptoms (e.g., 719.44 [Pain in joint, hand]; 726.4 [Enthesopathy of wrist and carpus]; 782.0 [Disturbance of skin sensation]; or 782.3 [Edema]) is crucial to justifying diagnostic testing for CTS. Do not use a "rule-out" diagnosis of 354.0 to substantiate medical necessity, because this unfairly labels the patient as having a condition that he or she may not have. Also, insurers do not accept rule-out diagnoses to justify diagnostic testing. 

The severity and persistence of the patient's symptoms determine the approach to treating CTS. The neurologist first meets with the patient to discuss test results, provide counseling and offer advice on alleviating symptoms. Patients are often relieved enough to carry on with daily activities simply by taking frequent breaks or avoiding repetitive tasks when using their hands or by incorporating massage or stretching techniques into their routine. Such a visit may be reported using the appropriate established patient E/M code (99212-99215). If more than half the visit comprises counseling or coordination of care, time may be used as the controlling factor to determine the appropriate E/M level. For instance, CPT notes that a level-four established patient visit (99214) typically involves 25 minutes of patient/physician face-to-face time. Therefore, if the majority of a 30-minute visit is spent counseling the patient on methods to treat himself or herself, 99214 may be reported based on time alone. 
 
If conservative self-treatment and behavior modification options fail, a patient with mild CTS symptoms may be treated using wrist splints, steroid injections, anti-inflammatory drugs, physical therapy or a combination of any of these. Surgical intervention may be necessary if symptoms fail to respond to nonsurgical treatment in three months. Failure to follow this progression may result in denials based on a lack of medical necessity, notes Dianna Hofbeck, RN, CCM, ACFE, president of North Shore Medicine Inc., a national billing service in southern New Jersey. "It's important to demonstrate to the insurer that the treatment you provide is justified. Insurers shouldn't be expected to pay for unnecessary procedures or services."
 
Note: In cases where CTS may result from a systemic condition such as diabetes, treating the systemic condition can also relieve the symptoms of CTS. Therefore, insurers generally require that treatment of the systemic condition also occur before CTS treatments will be reimbursed.

Physical therapy is generally the first treatment option for CTS. Although carrier guidelines vary, the following codes are typical of those accepted for CTS treatment:
 

97010 Application of a modality to one or more areas; hot or cold packs
 

97110 Therapeutic procedure, one or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility
 

97112 ... neuromuscular reeducation of movement, balance, coordination, kinesthetic sense, posture, and/or proprioception for sitting and/or standing activities
 

97124 massage, including effleurage, petrissage and/or tapotement (stroking, compression, percussion)
 

97139 Unlisted therapeutic procedure (specify)
 

97150 Therapeutic procedure(s), group (2 or more individuals)
 

97530 Therapeutic activities, direct (one-to-one) patient contact by the provider (use of dynamic activities to improve functional performance), each 15 minutes
 

97535 Self-care/home management training (e.g., activities of daily living [ADL] and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment) direct one-on-one contact by provider, each 15 minutes
 

98925 Osteopathic manipulative treatment (OMT); one to two body regions involved.
 
 
Most states require that a physical therapist or occupational therapist provide these services under the direction of a physician, says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, consultant and CPC trainer for A+ Medical Management and Education in Egg Harbor City, N.J. Therefore, the neurologist could either provide these services or refer the patient to a therapist and provide the required follow-up, documenting, coding and billing each visit.

Splinting Helps Nighttime Symptoms
 
 
If physical therapy fails, more aggressive approaches may be needed. Splinting may follow or be employed with physical therapy or prescription anti-inflammatories. Specifically, a splint that holds the wrist still while the patient sleeps often helps relieve nighttime symptoms of tingling and numbness. Splint application is reported using 29125 (Application of short arm splint [forearm to hand]; static) or 29126 ( dynamic) as appropriate, depending on whether the splint allows movement of the wrist. Append the -LT (Left side) or -RT (Right side) modifiers, with supporting documentation, to designate the location of the splint, Hofbeck recommends. If splints must be applied bilaterally, report 2912x-LT and 2912x-RT. If the neurologist has a durable medical equipment regional carrier (DMERC) number and provides the splint(s), he or she may also bill the appropriate HCPCS supply code (e.g., A4570, Splint).
 
Note: DMERC carriers may be contacted by region: Region A (Northeast), www.uhc.com; Region B (Midwest), www.astar-federal.com/anthem/affiliates/adminastar/ dmerc/index.html; Region C (South), www.pgba.com;Region D (West) www.cignamedicare.com/dmerc.
 
CPT notes that an additional E/M service may be charged with the splint application only if "significant identifiable services are provided" at the same time and modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) is appended to the E/M code.
 
Injections, Surgery Considered Last Resorts

If splinting fails to alleviate the patient's symptoms, the neurologist may administer steroid injections, including cortisone or other drugs, as a last resort before recommending surgery. Injections are particularly useful in pregnancy-related CTS (which often abates after delivery) and may provide relief for six months or longer.  

Depending on the payer, applicable injection codes include 20605* (Arthrocentesis, aspiration and/or injection; intermediate joint, bursa or ganglion cyst [e.g., temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa]), 20550* (Injection; tendon sheath, ligament, ganglion cyst) and 90799 (Unlisted therapeutic, prophylatic or diagnostic injection). When using injections to treat bilateral CTS, append modifiers -LT and -RT as appropriate, Hofbeck says. Bilateral injections should be reimbursed as independent procedures, and are often provided at different visits (e.g., the left wrist is injected Tuesday, and the patient returns Friday for an injection in the right wrist). Bill separately for the drug using the appropriate HCPCS supply code.
 
Insurers vary in the number of injections they will cover. Palmetto GBA, the Part-B carrier for South Carolina, for instance, specifies that up to three injections per year may be covered (policy # 95-0007-L). More than three injections per site (or more than six injections for all sites in any 12-month period) requires further documentation to substantiate the medical necessity for these procedures.
 
According to the Medicare Carriers Manual (MCM), section 15010, Medicare will allow billing of a 907xx series code and the supply (J) code only if no other service is provided during the same visit. If the neurologist provides an E/M service in addition to the injection, for instance, only the supply code may be billed: The administration is part of the E/M service and will not be reimbursed separately.
 
An E/M code may be billed in addition to surgical injection codes 20550* - 20610* only if the E/M service meets the requirements of modifier -25 (i.e., significant and separately identifiable) and that modifier is appended to the appropriate E/M code. If the primary reason for an established patient visit is the injection, report only the injection code.
 
Note: If nonsurgical approaches fail to alleviate the patient's symptoms, the neurologist will refer the patient for surgical treatment. The neurologist may be involved in the patient's postoperative care in some cases. Again, splinting and physical therapy may be appropriate.

Workers' Compensation Issues Addressed

CTS is commonly a work-related problem. Section 2370.1 of the MCM requires compensation for injury or disease suffered in connection with employment "whether or not the injury was the fault of the employer." Codes 99455 (Work-related or medical-disability examination by the treating physician ) and 99456 ( by other than the treating physician) are specifically designated to report work-related or medical-disability evaluations. Report follow-up services with the appropriate CPT codes.
 
Attach a diagnosis of 354.0, along with any applicable E codes which help clarify the exact cause of the injury to the claim. For instance, if CTS occurs on the job as a result of trauma from a car-to-car collision, report E81x (Motor vehicle traffic accident ). E codes are always secondary diagnoses.
 
Workers' compensation guidelines vary, and prior authorization from the insurer is always wise.