Neurology & Pain Management Coding Alert

Include all manifestation codes to help support treatment.

Your neurologist may be seeing an influx of patients with diabetic neuropathy, so you'll need to know these crucial diagnosis and treatment tips to accurately report care for this common condition.

Trend: Approximately half of the 25.8 million diabetes patients in the U.S. have diabetic neuropathy, a painful nerve disorder. Patients might be referred from their endocrinologist to either a neurologist or pain management specialist for care.

Narrow Your Diagnosis Choices

Patients often have multiple diagnoses and treatments related to their diabetes that your provider must consider during treatment -- and that you should consider during coding.

"The one problem I have is that the doctors don't specify in the medical record the type of diabetes the patient has and if it is controlled or uncontrolled," says Vonda Pickelsimer of Neurology Associates of Greenville, S.C. "I also notice that the medical record doesn't always specify the diabetes as primary or secondary with the neurological manifestation."

If you encounter the same situation with your providers, encourage them to document more details so you can select the diagnosis based on the highest level of specificity.

The code for diabetic neuropathy (250.6x, Diabetes with neurological manifestations ...) needs a fifth digit explaining the type of diabetes manifestation. Your subclassification choices are:

• 0 -- type II or unspecified type, not stated as uncontrolled
• 1 -- type I [juvenile type], not stated as uncontrolled
• 2 -- type II or unspecified type, uncontrolled
• 3 -- type I [juvenile type], uncontrolled.

If the patient has secondary diabetes with neurological manifestations, you'll choose from the 249.6x (Secondary diabetes mellitus with neurological manifestations ...) code family instead.

Extra code: ICD-9 coding guidelines direct you to also report a code describing the manifestation, in addition to the diabetes, however, sequencing the 250.6X code first. Coding options for the associated conditions your provider might document could lead you to mononeuropathy (354.0-355.9), peripheral autonomic neuropathy (337.1), polyneuropathy (357.2), or others.

Watch for Injection Type

A patient's actual treatment depends on the specific area affected and the type of pain she has. These factors - along with the patient's pain threshold and how she reacts to medications - determine how often the physician administers treatments.

"Diabetic neuropathy is typically treated with oral medications," says Catherine French, manager of medical economics for the American Association of Neuromuscular & Electrodiagnostic Medicine. "People with severe pain might benefit from additional treatment options to reduce pain and increase physical function."

Other common treatments for diabetic neuropathy include topical application of capsaicin creams or lidocaine patches. Complementary therapies such as acupuncture (97810-97814), physical therapy (including exercises, stretching and/or massage), TENS units (transcutaneous electrical nerve stimulation), and low-level laser therapy can be helpful in some patients.

Injection options: The neurologist or pain management specialist might also administer nerve blocks to temporarily interrupt the impulse conduction in peripheral nerves or nerve trunks. His first step could be administering a diagnostic block to determine the source of the patient's pain. Once the source of pain is known, the patient could return for a therapeutic nerve block.

Tip: Whether coding a diagnostic or therapeutic procedure, knowing whether your provider performed an injection to a particular site or administered a neurolytic will point you in the right direction. Common coding options for these situations include:

• 64400-64450 -- Injection, anesthetic agent ...
• 64505-64530 -- Injection, anesthetic agent ... to various sympathetic nerves.

Final note: Because the patient continues seeing her endocrinologist or primary care physician for other aspects of diabetes care, work with that physician to ensure you code your provider's services correctly. Some payers might deny claims if multiple physicians caring for the patient use the same diagnosis code.