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 Solid Diagnosis
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. 
Patient Counseling Determines Approach
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. [...]