Neurology & Pain Management Coding Alert

Follow these 4 steps to help avoid audit woes.

Picture this: Your neurologist treats a patient who complains of chronic pain. Your neurologist, however, is unable to assign a definitive diagnosis during the visit. You know better than to alter or guess a diagnosis to ensure payment; now learn about appropriate codes that can help you handle the situation.

1. Stay Sharp Interpreting Documentation

Specificity in diagnosis coding is always important, but it is increasingly vital because "third party payers are establishing more stringent coverage criteria for therapies and procedures and are using automated edits to deny claims based on the lack of a covered diagnosis," says Mary H. McDermott, MBA, CPC, with Johns Hopkins University in Baltimore. "Using a non-specific diagnosis code which may be 'close' -- but not exact -- may mean you won't be paid for a service due to a Medicare Local Coverage Determination [LCD] or a third-party medical policy," McDermott points out. Opting for less specific codes also might mean you receive payment for a service that would not be covered under the correct diagnosis.

Both of these scenarios present different problems. Using the most specific appropriate diagnosis for the patient and making sure it is well documented in the medical record will help ensure appropriate reimbursement for the provider and appropriate coverage for the patient.

Changes: "In the past, providers tended not to worry as much about picking the exact diagnosis code because it had little, if any, impact on payment," McDermott says. Nowadays, payers might only cover services, procedures and/or drugs for very specific diagnosis codes. "Using the incorrect diagnosis may limit coverage or may get you paid for services that are not covered, which increases your risk during audit," McDermott says.

2. Apply 'Precise Dx' Lesson

Consider the following scenario and how you would select a diagnosis.

Patient A presents at your office complaining of severe, chronic pain in the right side of his back. The pain began about ten months ago. Your neurologist performs an examination and then administers two trigger point injections in the right lumbar multifidus muscle for pain relief. However, his chart notes say only that the patient had "back pain."

The chart: You receive the chart and see your neurologist performed trigger point injections on other patients in the past, using 20552 (Injection[s]; single or multiple trigger point[s], one or two muscle[s]). The most recent injections performed on the other patients' backs were for myofascial pain.

In the absence of a more specific diagnosis, should you assume that Patient A also has myofascial pain, and report one unit (because trigger point injection coding is based on the number of separate muscles injected and not the quantity of injections performed) of 20552 with a diagnosis of 729.1 (Myalgia and myositis, unspecified)?

Answer: No. Making assumptions doesn't support compliant coding. "From a clinical standpoint, pain can be caused by a myriad of reasons," explains Leslie Johnson CCS-P, CPC, director of coding and education for Medi-Corp, Inc., in Cranford, N.J. "Coders aren't clinicians and shouldn't make presumptions, even if the diagnosis seems evident. From a coding perspective ��" and especially with the spotlight on neurology pain management procedures in conjunction with medical necessity ��" assuming a previous diagnosis is the reason for the current encounter could be courting disaster."

LCD check: Some payers will reimburse for 724.5 (Backache, unspecified) for trigger point injections, so be sure to study your payer coverage policies carefully before determining if the diagnosis fits the payer's rules. Physicians treat patients based on what they believe suits the patient's needs, but their opinions don't always match payer guidelines. "A coder needs to be aware of thepayer policies and LCDs to be able to relay that information to the physician so revenue isn't lost by 'good doctoring,' as Medicare once wrote about medical necessity," Johnson says.

3. Look for Prior Conditions Before Coding for Pain

Prior conditions can contribute to current complaints. When faced with that situation, your physician should document -- and you should code -- the prior conditions if they affect management of the current condition.

Example: "Prior trauma, such as a previously broken bone, can cause patients to experience back or neck pain," McDermott says. "If a patient's pain stems from a previous condition, that diagnosis can also be coded to justify these diagnostic/ therapeutic procedures."

Depending on the circumstances, you might be able to report a late effect code to show the causal effect or a V code to report a personal history of trauma. In a situation where chronic neck pain was present due to a prior traumatic vertebral fracture -- at C2-C3, for example -- you could code this as:

• 338.21 -- Chronic pain due to trauma
• 723.1 -- Neck pain
• 905.1 -- (Late effect of cervical closed fracture) or V15.51 (Personal history of injury; healed traumatic fracture).

Your coding might be different for a pathologic fracture, such as 338.21, 723.1, and V13.51 (Personal history of healed pathologic fracture). "The key to the correct coding of these contributory conditions is making sure they are appropriately documented in the medical record," McDermott emphasizes.

4. Watch for Comprehensive Problems

Patient B comes to your facility complaining of chronic pain in her lower back and right thigh. Your neurologist provides a facet joint nerve block at L4/L5 and writes "lumbar, thigh pain" on Patient B's chart.

You read the chart and look up the code for facet joint injection (64493, Injection[s], diagnostic or therapeutic agent, paravertebral facet [zygapophyseal] joint [or nerves innervating that joint] with image guidance [fluoroscopy or CT], lumbar or sacral; single level). But when you check the approved diagnoses, neither lumbar pain nor thigh (limb) pain is listed as acceptable. What's your next step?

Answer: Check with your neurologist to verify Patient B's condition. Often, you will learn the patient has a more comprehensive problem, such as 721.3 (Lumbosacral spondylosis without myelopathy). In that case, after your provider documents the spondylosis as a correction or addendum, only code the patient's main condition, 721.3. You should not additionally report the patient's pain symptoms. The ICD-9 official guidelines instruct coders that "Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification."