Neurology & Pain Management Coding Alert

CTS diagnosis a must for some, but not all, payers on 20526.

Coders that can't cope with the intricacies of reporting therapeutic injections for carpal tunnel syndrome (CTS) are setting their practices up for potential failure.

Reason: You'll probably need a CTS diagnosis in order to report 20526 (Injection, therapeutic [eg, local anesthetic, corticosteroid], carpal tunnel). Then again, some payers don't explicitly require a CTS diagnosis for 20526, so you might have to do some research. You'll also have to document previous attempts to treat the CTS, and master the different ways you can report bilateral CTS shots.

Confused? Don't worry; we've got a couple of experts here to help us plow through the fact - and fiction - of coding therapeutic CTS injections.

Myth: You Must Have a CTS Diagnosis to Report 20526

Reality: This is largely, but not entirely, true. For most Medicare (and non-Medicare) providers, the patient must have a CTS diagnosis when you report 20526.

Cathy Satkus, CPC, coder at Harvard Family Physicians in Tulsa, Oklahoma, says that Medicare Administrative Contractor (MAC) Novitas only covers the following ICD-10 codes:

• G56.00, Carpal tunnel syndrome, unspecified upper limb
• G56.01, ... right upper limb
• G56.02, ... left upper limb
• G56.03, ... bilateral upper limbs.

There might be exceptions to this diagnosis coding rule, but they would be exceptionally rare. "The main diagnosis to use for 20526 would usually be G56.00 to G56.03," says Dreama Sloan-Kelly, MD, CCS, president of Dr. Sloan-Kelly Consulting in Shirley, Massachusetts. "However, I encourage all clients to refer to their local Medicare carrier's LCDs [local coverage determinations]. It is a great resource for ICD-10 diagnosis codes that support medical necessity."

For example, Sloan-Kelly points out Noridian's LCD, which doesn't flat-out forbid you from reporting 20526 with a non-CTS diagnosis. In fact, the LCD lists dozens of diagnosis codes that might support medical necessity for the following CPT^® codes:

• 20526
• 20527, Injection, enzyme (eg, collagenase), palmar fascial cord (ie, Dupuytren's contracture)  
• 20550, Injection(s); single tendon sheath, or ligament, aponeurosis (eg, plantar "fascia")
• 20551, Injection(s); single tendon origin/insertion 
• 28899, Unlisted procedure, foot or toes.

This does not mean that you can report 20526 for any of the ICD-10 codes listed in Noridian's coverage determination; it does, however, mean that the payer has not explicitly forbidden 20526 reporting with a non-CTS diagnosis.

Best bet: If you're going to file a 20526 claim with a diagnosis other than CTS, tread softly: Check your payer contract, contact a payer rep, and get approval from your supervisor to file this claim. You don't want payers' ears to perk up on these claims; the biggest red flag for 20526 claims is often a lack of a CTS diagnosis.

To check out Noridian's LCD on these injections, go to: https://med.noridianmedicare.com/documents/10546/6990981/Injections+-+Tendon, Ligament, Ganglion+Cyst, Tunnel+Syndromes+and+Morton's+Neuroma+LCD/fae75e02-cbbd-4630-a012-e37dd6360472.

Myth: You Can Report 20526 Without Prior Treatment Evidence

Reality: In order to properly report 20526, you need recorded evidence of failed previous attempts to alleviate the CTS, confirms Sloan-Kelly. Make sure the patient's medical record reflects these attempts.

"Essentially, clinical documentation must show that more conservative treatments, such as NSAIDS [nonsteroidal anti-inflammatory drugs], have failed or are contraindicated," she explains. "I always encourage all providers to give an explanation for why it failed - so for instance, in regard to NSAID they should document the patient had very little to no pain relief and describe the pain on a scale of 1 to 10 as always.

"If the provider is stating more conservative [CTS] treatments were contraindicated, they again must state why," Sloan-Kelly continues.

Some forms of prior treatment that might allow for 20526 payment include:

• Tendon sheath, ligament, or tendon injections (20550 [Injection(s); single tendon sheath, or ligament, aponeurosis (eg, plantar "fascia")] or 20551 [... single tendon origin/insertion]);
• trigger point injections, or TPIs (20552 [Injection(s); single or multiple trigger point(s), 1 or 2 muscle(s)] or 20553 [...  single or multiple trigger point(s), 3 or more muscle(s)]);
• course of prescribed prednisone or NSAID;
• wearing wrist braces; or
• a course of physical therapy (PT).

Remember, this is not an exhaustive list. There are other forms of CTS treatment the provider might employ before opting for 20626. No matter the treatment, be sure to note it in the documentation for your CTS patient.

Myth: When You Report 20526, You Can't Report Drug Supply

Reality: "All providers should bill for the drug supply separately - paying close attention to the dosage to make sure they are coding the correct units," explains Sloan-Kelly. "The most common injectable used for 20526 is J1030 [Injection, methylprednisolone acetate, 40 mg]."

Myth: There Is Only 1 Way to Code Bilateral CTS Release

Reality: It depends on the payer, according to Satkus. What follows is a list of the most common ways to report bilateral CTS release:

• 20526 with modifier 50 (Bilateral procedure) appended on one line;
• 20526 x 2 on one line with modifiers RT (Right side) and LT (Left side) appended;
• 20526 with modifier RT appended on one line, and 20526 with modifier LT appended on the second line; and
• 20526 on one line, and 20526 with modifier 50 appended on the second line.

Best bet: You'll definitely want to make sure you know how your payer wants you to report bilateral 20526 claims before you file the claim. As evidenced above, there are a lot of permutations to this coding combination.