Neurology & Pain Management Coding Alert

Question: During an initial consult with a new patient, our neurologist suspected a diagnosis of carpal tunnel syndrome (354.0). Should I use this diagnosis to justify medical necessity for future procedures?

Tennessee Subscriber
 
Answer: No. Until testing confirms the carpal tunnel diagnosis, you should rely on signs and symptoms to justify any services the physician provides. Typical signs and symptoms indicative of carpal tunnel syndrome include 719.44 (Pain in joint, hand), 726.4 (Enthesopathy of wrist and carpus), 782.0 (Disturbance of skin sensation) and 782.3 (Edema).
  
For 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 and list the signs and symptoms as secondary diagnoses.
 
But if the neurologist conducts the appropriate testing but the results are inconclusive or negative for carpal tunnel syndrome, you should rely on the signs and symptoms only to establish medical necessity for the tests the neurologist conducts, as well as any E/M service he provides.
 
Remember: ICD-9 coding guidelines state that you should not report -rule-out- diagnoses in the outpatient setting. This approach avoids labeling the patient with an unconfirmed diagnosis while still allowing for reimbursement for the physician even if testing cannot establish a definitive diagnosis.
 
In other words, you shouldn't claim a diagnosis of 354.0 in the hopes of receiving payment if the neurologist has not or cannot definitively establish a carpal tunnel syndrome diagnosis. Rather, the neurologist's documentation should be strong enough to support the claim with the signs-and-symptoms diagnoses alone, regardless of the outcome of diagnostic testing.