Neurology & Pain Management Coding Alert

Think coding carpal tunnel syndrome is easy? After all, ICD-9 includes only one diagnosis: 354.0 (Carpal tunnel syndrome). Carrier policies can complicate matters, however, so follow these guidelines to ensure proper reimbursement -- even if diagnostic testing doesn't establish a definitive diagnosis up front.

Even if your neurologist suspects a patient has carpal tunnel syndrome (CTS), reporting diagnosis 354.0 before he completes all testing might limit your options down the road. While you're waiting for test results, report the patient's symptoms to justify any services your physician provides. Typical signs and symptoms of CTS can include:

• numbness and tingling (782.0)

• aching pain in the thumb, index, and middle fingers that might move up the arm (729.5)

• hand and grip muscle weakness (728.87)

• feeling of swollen hand (729.81).

Diagnosis tip: Use caution before automatically assigning 354.0. "CTS is not the only disease process that can cause the symptoms generally associated with CTS," explains Rena Hall, CPC, billing/insurance coordinator at Kansas City Neurosurgery Group in Missouri. Inflammation caused by arthritis, pregnancy, obesity, hypothyroidism, repetitive motion disorder (RMD), and diabetes can mimic symptoms of CTS.

If you do have a conclusive definitive diagnosis, however, you should use it instead of signs and symptoms. ICD-9 guidelines state, "Signs and symptoms that are integral to a disease process should not be assigned as additional codes."

Example: Your neurologist completes nerve conduction studies (95900, Nerve conduction, amplitude and latency/velocity study, each nerve; motor, without Fwave study; and 95904, ... sensory) and electromyography (95860, Needle electromyography; one extremity with or without related paraspinal areas) and confirms a carpal tunnel syndrome diagnosis. Now that you have conclusive test results, you can report 354.0 as the primary diagnosis.

Why: You report signs and symptoms only if your physician doesn't confirm CTS or if the patient has additional signs and symptoms not associated with CTS. If your physician diagnoses CTS after procedures, such as 95900 or 95904, you should not report signs and symptoms as secondary diagnoses. These are integral to the primary definitive diagnosis, so they don't need separate reporting.

Don't mix up guidelines for reporting an electromyogram (EMG) versus a nerve conduction study (NCS). "EMGs are usually done for more proximal lesions," says William J. Mallon, MD, medical director of Triangle Orthopaedic Associates in Durham, N.C. "NCSs are mostly done for CTS diagnosis. The EMG rules out other problems, such as cervical radiculopathy." When coding an EMG, be sure to choose the code that properly reflects the number of limbs your physician tests.

For example, your provider performs a complete EMG study on an extremity or both extremities. If the patient has carpal tunnel syndrome and is tested in only one upper extremity, submit 95860; if the patient has CTS in both hands and both upper extremity muscles are tested, report 95861 (... 2 extremities with or without related paraspinal areas).

NCS difference: You code NCSs (such as 95900) according to the number of individual nerves tested. Many carriers limit the number of NCSs during a single session and/or during a certain period of time. For example, some carriers will reject claims for more than eight NCSs performed on a patient over a six- or eight-month period. Your neurologist could reach that limit in a single session, so check your individual payer's coverage policies. "In more classic, severe cases, NCSs are not necessary to make the diagnosis," Mallon says. "The American Academy of Orthopaedic Surgeons (AAOS) current treatment algorithm requires that they be obtained only if the physician is not certain of the diagnosis."

CPT help: Check the "Type of Study/Maximum Number of Studies" table at the end of CPT's Appendix J for more information. This table helps you substantiate the number of test units for multiple needle EMGs, NCSs, or other EMG studies that you can have for various diagnoses.

Physicians often use a range of noninvasive, conservative treatments for patients in the early stages of CTS. "Each insurance carrier, including many workers' compensation regulations, has its own set of guidelines pertaining to treatment of CTS," Hall says. "Contact your carrier for specifics before moving to the next treatment step."

A patient often begins treatment by taking over-thecounter pain medications and wearing an "off-the-shelf" wrist brace or splint, although a therapist may make the patient a custom brace, if necessary.

Injection option: If NSAIDs, splints, and physical therapy have either failed to help the patient's condition or are not otherwise indicated, your physician might administer injections into the carpal tunnel to relieve discomfort. You'll report this service with 20526 (Injection, therapeutic [e.g., local anesthetic, corticosteroid]; carpal tunnel). If your physician injects both of the patient's wrists during CTS treatment, bill it as a bilateral service with either modifier 50 (Bilateral procedure) or modifiers LT (Left side) and RT (Right side). Check which option the carrier prefers for bilateral claims.