Neurology & Pain Management Coding Alert

Be careful not to put words in your neurologist's mouth, or risk audit woes.

Imagine your neurologist providing pain management services for a patient presenting with a complaint of chronic pain, but at the time of the visit your neurologist is unable to uncover a definitive diagnosis. While you know that altering or guessing a diagnosis to ensure payment is a huge no-no, there are proper codes you can choose from to handle the situation.

Specificity in diagnosis coding is always important, but it is increasingly vital because-"third party payers are establishing more stringent coverage criteria for therapies and procedures and are using automated edits to deny claims based on the lack of a covered diagnosis," says Mary H. McDermott, MBA, CPC, with Johns Hopkins University in Baltimore.

"Using a non-specific diagnosis code which may be -close-- but not exact-may mean you will-not be paid for a service due to a Medicare Local Coverage Dectermination [LCD] or a third-party medical policy," McDermott points out. Or it may mean you are incorrectly paid for a service for which there would be no coverage if you had used the correct diagnosis.-

Both of these scenarios are problematic in different ways. Using the most specific appropriate diagnosis for the patient and making sure it is well documented in the medical record will help ensure appropriate reimbursement for the provider and appropriate coverage for the patient.

"In the past, providers tended not to-worry as much about picking the exact diagnosis code because it had little, if any, impact on payment," McDermott says.-"Increasingly, drugs and procedures may only be covered for very specific-diagnosis codes, so using the incorrect diagnosis may limit coverage or may-get you paid for services that are not covered, which increases your risk during audit."

Patient A presents at your office complaining of severe, chronic pain in the right side of his back. The pain began about ten months ago. Your neurologist performs an examination and then provides two trigger point injections in the right lumbar multifidus muscle for pain relief. However, his chart notes say only that the patient had "back pain."

You receive the chart and see your neurologist performed trigger point injections on other patients in the past, using 20552 (Injection[s]; single or multiple trigger point[s], one or two muscle[s]). The most recent injections performed on the other patients- backs were for myofascial pain.

In the absence of a more specific diagnosis, should you assume that Patient A also has myofascial pain, and report one unit (because trigger point injection coding is based on the number of separate muscles injected and not the quantity of injections performed) of 20552 with a diagnosis of 729.1 (Myalgia and myositis, unspecified)?

Answer: No. Assumptions are not sufficient for compliant coding. If your neurologist did not specifically document myofascial pain or myalgia and you use one of those codes, you could find yourself in trouble in the event of a payer audit. Such errors are exactly the kind of thing that auditors keep an eye out for, says Laureen Jandroep, OTR, CPC, CPC-H, senior instructor for CodingCertification.Org, an online coding certification training center in Galloway, N.J.

Is back pain (724.5) the same thing as myalgia (729.1)? No. "The patient's -generic- back pain symptom may be due to many different conditions, which could include muscular causes," Jandroep says. "The myalgia diagnosis is usually a covered ICD-9 code, but back pain is usually not. The coder can't just pick myalgia because it is -close- and is on the approved list."

If the patient does not have an actual diagnosis listed as acceptable on the LCD, you cannot substitute one to get paid.

Read up on LCDs: Some payers will reimburse for 724.5 (Backache, unspecified) for trigger point injections, so be sure to study your payer coverage policies carefully before determining if the diagnosis fits the payer's rules. "You have to be as specific as you can," Jandroep says. "This may mean that your physician performs services that are not ultimately going to be reimbursed or may need to more accurately document the medical reason for performing the service."

Look for Prior Conditions Before Coding for Pain

Prior conditions contributing to current complaints should be documented and coded if they affect the management of the current condition.

For example, "prior trauma, such as a previously broken bone, can cause patients to experience back or neck pain," McDermott says. "If a patient's pain stems from a previous condition, that diagnosis can also be coded to justify pain management procedures."

Depending on the situation, there may be late effect codes-or V codes-that can be coded in addition to the current complaint that show a late effect or a personal history of trauma. In a situation where chronic neck pain was present due to a prior traumatic vertebral fracture -- at C2-C3, for example -- you could code this as:

- 338.21 -- Chronic pain due to trauma and

- 723.1 -- Neck pain and

- 905.1 -- Late effect of cervical closed fracture.

Or you could code this scenario as 338.21, 723.1, and V15.51 (Personal history-of injury-healed traumatic fracture).

If the fracture was a pathologic fracture the coding might be different, such as 338.21, 723.1,-and V13.51 (Personal history of healed pathologic fracture). "The key to the correct coding of these contributory conditions is making sure they are appropriately documented in the medical record," McDermott emphasizes. Ensuring that your provider is aware of how important this information is to justify medical necessity is key.

Patient B comes to your facility complaining of chronic pain in her lower back and right thigh. Your neurologist provides a facet joint nerve block at L4/L5 and writes "lumbar, thigh pain" on Patient B's chart.

You read the chart and look up the code for facet joint injection (64475, Injection, anesthetic agent and/or steroid, paravertebral facet joint or facet joint nerve; lumbar or sacral, single level). But when you check the approved diagnoses, neither lumbar pain nor thigh (limb) pain is listed as acceptable. What's your next step?

Answer: Check with your neurologist to verify Patient B's condition. Often, you will learn the patient has a more comprehensive problem, such as 721.3 (Lumbosacral spondylosis without myelopathy). which wasn't noted. In that case, after your provider documents the spondylosis as a correction or addendum, only code the patient's main condition, 721.3. You should not additionally report the patient's pain symptoms. The ICD-9 official guidelines instruct coders that "Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification."