Neurology & Pain Management Coding Alert

What should you do if your neurologist provides pain management services for a patient with chronic and acute pain but who does not exhibit a definitive and exact diagnosis? Although you may be tempted to alter diagnoses to ensure payment, this is unnecessary and far from the best solution.

 When reporting diagnoses, you should always be as exacting as possible. "Specificity is crucial," says Teresa Thompson, CPC, an independent coding and reimbursement specialist in Sequim, Wash.

 For instance, consider the following scenario: A patient comes to the office complaining of severe, chronic pain in her lower back, which started two months ago. Following examination, the neurologist performs two trigger point injections to relieve the patient's pain. His chart notes indicate that the patient had "back pain."

 The coder receives the chart and notes that the neurologist has performed trigger point injections in the past and coded them using 20552 (Injection[s]; single or multiple trigger point[s], one or two muscle[s]). She recalls that the most recent injections performed on patients' backs were for sciatica, and she assumes in the absence of a more specific diagnosis that the present patient also has sciatica. She reports one unit of 20552 (because both injections were performed on the same site, which would not warrant billing two units) with a diagnosis of 724.3, and the carrier pays the claim accordingly. But just because the claim is paid does not mean that it was coded correctly.

 "If a patient does not have a diagnosis listed as acceptable on the local medical review policy [LMRP], you cannot create one just to get paid," says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, CCS, director and senior instructor for CRN Institute, an online coding certification training center based in Absecon, N.J. "Is back pain the same thing as sciatica? No. But the practice will probably get paid because sciatica is on the approved list." If your physician did not specifically document sciatica, you could be in trouble during an audit. "This is the kind of thing that the OIG [Office of Inspector General] is targeting," Jandroep says.

 For instance, some carriers reimburse for "backache, unspecified" (724.5) for trigger point injections, so you should read your LMRP carefully to determine whether the diagnosis fits the payer's rules. "You have to be as specific as you can," Jandroep says, "which may sometimes mean that your physician performs services that are not ultimately going to be reimbursed. If you anticipate that the payer will not honor the injection codes based on the diagnoses [such as "generalized pain," 780.99], you can ask the patient to sign an ABN [advance beneficiary notice] prior to the injection." Although an ABN may not be popular with patients, it's far better than forfeiting reimbursement or committing fraud.

 Tip: A good practice is to have a special symbol (for instance, a "#" or "*") placed next to diagnoses on your superbill that require an ABN. This makes the physician and the office staff aware immediately.

 Often, patients with conditions such as back or neck pain are actually suffering from effects caused by prior trauma, such as a broken bone. If the pain is caused by a previous condition, that diagnosis can sometimes be used to justify pain management procedures, says Sheila Belcher, provider reimbursement consultant at Carilion Professional Billing in Roanoke, Va., who bills for 20 physicians. "Ninety percent of the pain management procedures that we bill come from some type of trauma, and we can often code the claim using the underlying problem instead of current symptoms. We look at the reason the patient is in rehabilitation in the first place and determine whether that is the root of the problem."

 For example, a patient presents with chronic pain in her lower back and right thigh. The physiatrist performs a facet joint nerve block at L4/L5 and writes "lumbar, thigh pain" on the chart. The coder reads the chart and looks up the code for the facet joint injection (64475, Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; lumbar or sacral, single level). She looks over the approved diagnoses, and neither lumbar nor thigh pain is listed as acceptable.

 Belcher recommends discussing the patient's condition with the physician and suggests that the coder  will frequently learn that the patient has a more comprehensive problem, such as postlaminectomy syndrome (722.80-722.83). "In that case, I would code the patient's main condition first, and her symptoms second."

 Therefore, code this claim using 722.83 for lumbar postlaminectomy syndrome, along with 724.2 for low back pain and 729.5 for pain in limb. Other "root" problems that often cause pain symptoms include carpal tunnel syndrome (354.0), scar conditions (709.2), displaced intervertebral discs (722.2), and rheumatic disorders (725-729).

 How can you distinguish preventive care from a standard "sick" visit? For example, the neurologist treats a patient with sciatica for two months, and the pain eventually subsides. The doctor asks the patient to return in six weeks to ensure that the symptoms aren't returning and that the problem isn't recurring. The patient comes into the office for his six-week visit with no problems and proves to be pain-free. Should you report an established patient E/M (99211-99215) or a preventive medicine service (99381-99397)?

 "You would base your coding on the documentation of whether the physician was following up on the patient's chronic pain condition," Jandroep says. "If the history is related to the same complaint or pain disorder, then you are providing an established E/M service and not a preventive visit." She adds that this is not a black-and-white issue, but states, "If I were billing this service, I would not code it as a well visit. Even though the patient's condition is not currently flaring up, you are managing her chronic problem and would code as 99211-99215."

 Belcher agrees: "A preventive visit would be billed if a physician saw a patient with no known chronic conditions who wanted to make sure they weren't developing any problems. If a patient had sciatica and they came back to ensure that it was resolved, I would use a V code to designate that the patient is status post to pain."

 In this scenario, you would code for the sciatica using 722.10 and V13.5 to demonstrate a personal history of musculoskeletal disorders. As the introduction to the V codes section of the ICD-9 manual states, V codes are appropriate "when some circumstance or problem is present which influences the person's health status but is not a current illness or injury."

 Almost all Medicare policies for pain management procedures include frequency guidelines. For instance, most carriers allow payment for only one pain management procedure per day (e.g., facet joint nerve block only, or trigger point injection only). Payers do not observe uniform frequency and usage guidelines for pain management procedures, and Jandroep advises checking with your payer for its guidelines. If pain management continues past a specified time (usually between 30 days and four months following surgery), the physician would have to demonstrate to the carrier why the patient required additional care.