Neurology & Pain Management Coding Alert

Find out when you should and shouldn't use 354.0

When you-re reporting carpal tunnel syndrome, you shouldn't always report 354.0 up-front. Follow our coding guidelines to ensure proper reimbursement, even if testing doesn't establish a definitive diagnosis.

Rely on the Signs

Even when a physician suspects that a patient has carpal tunnel syndrome (354.0), if you use that code before he completes all testing, you could limit your future range of billable tests.

In other words, until testing confirms the carpal tunnel diagnosis, you should depend on symptoms to justify any services the physician provides. Typical signs and symptoms indicative of carpal tunnel syndrome include numbness and tingling (782.0); aching pain in the thumb, index, and middle fingers that may move up the arm (729.5); hand and grip muscle weakness (728.87); and feeling of swollen hand (729.81).

Beware of Results That Are Inconclusive, Negative

Caution: If the neurologist conducts the appropriate testing but the results are inconclusive or negative for carpal tunnel syndrome, you should rely only on the signs and symptoms to establish medical necessity for the tests the neurologist conducts, as well as any E/M service he provides. But make sure your physician's documentation is strong enough to support the claim, regardless of the outcome of diagnostic testing.

Although your neurologist may suspect carpal tunnel, -CTS is not the only disease process that can cause symptoms generally associated with CTS,- says Rena Hall, CPC, billing/insurance coordinator at Kansas City Neurosurgery Group in Missouri. If you do have a conclusive diagnosis, however, you should use it.

Example: The neurologist conducts electrodiagnostic testing (such as nerve conduction studies, 95900, Nerve conduction, amplitude and latency/velocity study, each nerve; motor, without F-wave study; and/or electromyography, 95860, Needle electromyography; one extremity with or without related paraspinal areas) and confirms a diagnosis of carpal tunnel syndrome. In this case, you should report 354.0 as the primary diagnosis.

Remember ICD Guidelines

Note: Another standard study for CTS is 95904 (Nerve conduction, amplitude and latency/velocity study, each nerve; sensory). If your physician provides this service and diagnoses CTS (354.0), you do not need to report signs and symptoms as secondary diagnoses. The reason is that these diagnoses are integral to arriving at the primary diagnosis. ICD-9 guidelines state: -Signs and symptoms that are integral to a disease process should not be assigned as additional codes.-

Rule of thumb: You should only report signs and systems if your provider didn't confirm CTS, or if the patient had additional signs and symptoms not integral to CTS.

Watch Limbs Versus Units With EMGs, NCSs

Make sure you-re not mixing up the rules for reporting an electromyogram (EMG) and a nerve conduction study (NCS).

EMG key: When you code an EMG that your neurologist performs to diagnose or monitor carpal tunnel, you must be sure to choose the EMG code that properly reflects the number of limbs the neurologist stimulates, says Jayne Bosserman, billing clerk at Heartland Neurology in Lafayette, Ind.

Example: Your provider decides to perform a complete study on an extremity or both extremities. If the patient has carpal tunnel in only one hand, use 95860 (Needle electromyography; one extremity with or without related paraspinal areas). If the patient has CTS in both hands, use 95861 (... two extremities with or without related paraspinal areas).

NCS key: In contrast, you should bill nerve conduction studies, such as 95900, according to the number of individual nerves tested, Bosserman says. Note: Many carriers limit the number of NCSs. For example, some carriers will reject claims for any more than eight NCSs performed on a patient over a six- or eight-month period. Depending on the number of nerves tested, your neurologist could reach that limit in a single session. Contact your individual payers to determine what limitations you have.
 
Hint: You should also check CPT's Appendix J. You-ll find the -Type of Study/Maximum Number of Studies- table. This table can help you substantiate the number of multiple neuromuscular electrodiagnostic testing units you can have for various diagnoses.

Billing for CTS Treatment--Here's How

Your payers expect to see a progression from simple to more complex treatments.

Important: These steps have to be in the treatment plan, or payers will reject your claim based on lack of medical necessity.

Conservative treatment usually starts with physical therapy. If physical therapy does not help, the neurologist may have the patient wear a splint (29125, Application of short arm splint [forearm to hand]; static) to reduce symptoms, Hall says. This immobilizes the wrist but allows the hand to function as normal. A splint also helps to relieve nighttime symptoms. If this doesn't work, your neurologist may perform a nerve block.

The neurologist can also prescribe anti-inflammatory drugs or inject the affected area with a steroid such as cortisone (20526, Injection, therapeutic [e.g., local anesthetic, corticosteroid], carpal tunnel). The physician usually does this only when he has exhausted all other treatment methods. If the pain and numbness continue, a referral for surgery to remove the pressure on the median nerve is the next option.