Neurology & Pain Management Coding Alert
Dig Deep for Correct CRPS Dx
Question: Encounter notes indicate that the provider performed an office evaluation and management (E/M) service for an established patient with ‘CRPS 1 arm.’ Total encounter time was 27 minutes and involved low-level medical decision making (MDM). How should I report this encounter? Arkansas Subscriber Answer: Your CPT® coding answer is easy enough; report 99213 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter.) for the E/M service. The ICD-10 code you choose isn’t as clear, however. Your notes, indicative of complex regional pain syndrome 1 (CRPS I) can get you to G90.51- (Complex regional pain syndrome I of upper limb). If you want the most complete ICD-10 code, however, you can’t stop there. Do this: Go back and check the notes to see if the provider indicated laterality for the CRPS. Then, choose one of the following ICD-10 codes: Last resort: If you can’t get more information, append G90.519 (Complex regional pain syndrome I of unspecified upper limb) to 99213.
Related Articles
Neurology & Pain Management Coding Alert
- ICD-10 2023:
New Codes Detailing Dementia Debut
Keep learning new codes to avoid falling behind. Another issue of Neurology & Pain Management [...] - ICD-10 2023:
Substance Use, Poisoning Code Dx Groups Swell
Another well-represented group in 2023 is 2-wheeled vehicle accident diagnoses. Coders should look at the [...] - E/M Coding:
Use This Shared Knowledge to Shore Up Shared Billing Skills
Here’s why you need to know how documentation helps establish the patient’s medical narrative. If [...] - You Be the Coder:
Remember Add-On for Intercostal Shots
Question: Encounter notes indicate that the provider performed a steroid injection to two levels of an [...] - Reader Questions:
Dig Deep for Correct CRPS Dx
Question: Encounter notes indicate that the provider performed an office evaluation and management (E/M) service for [...] - Reader Questions:
Consider This Guidance on Unconventional Refill
Question: The PM specialist completed a patent test and aspirated all the medication out of the [...] - Reader Questions:
Keep Modifier 22 Atop Op Note Concerns
Question: I was told documentation for modifier 22 (Increased procedural services) should be a separate paragraph [...] - Reader Questions:
Use This Specific New Code for These Arrays
Question: When our provider implants a neurostimulator electrode array in the hypoglossal nerve using open technique, [...]
