Neurology & Pain Management Coding Alert

Neurologists who diagnose and treat carpal tunnel syndrome (354.0) often face difficulties obtaining appropriate reimbursement for their services because of the image carpal tunnel syndrome (CTS) has in the insurance community, the variety of ways to diagnose and treat CTS, and the bilateral billing issues that arise when carpal tunnel is diagnosed in both hands. But through thorough documentation and proper code choices, physicians can ensure correct billing and payment.

Daniel Hemker, a neurology coding specialist for Advantage Billing Service, a third-party biller in Tinley Park, Ill., says that many carriers still view carpal tunnel the way they might certain generic diagnoses such as back pain or neck pain. Carriers sometimes think theyre being scammed if you bill for it, Hemker reports. Full documentation is one of the keys to avoiding difficulties.

To say that a patients fingers hurt is not enough, Hemker adds. The neurologist needs to have detailed documentation of the presenting problem and all related symptoms, such as limited range of motion, and what the neurologist did to combat the syndrome.

Hemker explains that the carpal tunnel is a narrow passageway in the wrist that contains and protects the nerves and tendons extending into the hand. When the tissues in the carpal tunnel become swollen or inflamed, they put pressure on the median nerve, which provides sensation to the thumb, index, middle, and ring fingers. Excess pressure on this nerve produces the numbness and pain that characterize CTS. This problem may affect both wrists.

Identifying and Monitoring CTS

For example, a patient presents complaining of numbness and tingling in her wrists. She tells the neurologist that the symptoms get worse at night. The neurologist suspects that CTS may be present and asks the patient if the numbness is in every finger of her hand except the little finger (generally an indicator of CTS). The patient confirms that this is the case.

The neurologist performs a test for Tinels sign, which most carriers feel is a reliable indication that CTS is present. Atrophy or loss of bulk in the muscle of the thumb also may be an indicator. X-rays also can be performed.

The neurologist also may want to perform an electromyogram (EMG) (95860, needle EMG, one extremity with or without paraspinal areas; or 95861, needle EMG, two extremities with or without paraspinal areas) and a nerve conduction study (95900, nerve conduction, amplitude and latency/velocity study, each nerve; motor without F-wave study; 95903, nerve conduction, amplitude and latency/velocity study, each nerve; motor with F-wave study; or 95904, nerve conduction, amplitude and latency/velocity study, each nerve; sensory or mixed).

The neurologist must show medical necessity if he or she decides to perform an electromyogram or a nerve conduction study to diagnose CST because carriers feel that there are easier and less expensive ways to diagnose and monitor the condition.

Coding for CTS Nerve Conduction Studies and EMGs

When coding for EMGs performed to diagnose or monitor carpal tunnel, the coder must be sure to chose the EMG code that properly reflects the number of limbs stimulated. If the patient only has carpal tunnel in one hand, use 95860 (EMG for one extremity). If the patient has CTS in both hands, use 95861 (EMG for two extremities).

Nerve conduction studies, such as 95900 (nerve conduction study for motor nerves) and 95904 (nerve conduction study for sensory or mixed nerves) are billed according to the number of units performed. Coders should be aware, however, that many carriers limit the number of nerve conduction studies for which reimbursement will be made. For example, some carriers will reject claims for any more than eight nerve conduction studies performed on a patient over a six- or eight-month period. Depending on the number of nerves tested, that limit could be reached in a single session. The coder should contact the individual carriers in his or her area to determine what limitations may be in place as these may vary from state to state and even within different regions of a given state.

Appeals often will gain reimbursement for nerve conduction studies performed after a carriers limit has been exceeded, provided full documentation can be submitted that supports the medical necessity for using a great number of units within the prescribed time frame.

Elizabeth Brundage, office manager for MedSurg Billing, a coder with nearly 10 years experience in Forest Park, Ill., further indicates that workers compensation carriers often ask for full documentation with the bill.

Billing for Treatment of CTS

Hemker notes that insurance companies expect to see a progression from simple to more complex treatments. These steps have to be in the treatment plan, or youll get the claim rejected based on lack of medical necessity.

According to Hemker, conservative treatment usually starts with physical therapy. If physical therapy does not help, the neurologist will have the patient wear a splint (29125, application of short arm splint [forearm to hand]; static). This immobilizes the wrist but allows the hand to function as normal. A splint also helps to relieve nighttime symptoms. If this doesnt work, a nerve block occasionally may be performed.

The neurologist also can prescribe anti-inflammatory drugs or inject the affected area with a steroid such as cortisone. This usually is done only when all other treatment methods have been exhausted. If the pain and numbness continue, then a referral for surgery to remove the pressure on the median nerve is the next option.