Neurology & Pain Management Coding Alert

Question: An established patient with a history of carpal tunnel syndrome (CTS) reports to the provider complaining of tingling in her wrist and fingers. After a level-two evaluation and management (E/M) service, the provider confirms CTS is causing the tingling. The provider then injects a local anesthetic and sends the patient home. What is the correct coding for this encounter?

Maine Subscriber

Answer: On your claim, you should report the following:

20526 (Injection, therapeutic (eg, local anesthetic, corticosteroid), carpal tunnel) for the injection.

Modifier RT (Right side) or modifier LT (Left side) appended to 20526 to indicate laterality, if the payer requires it.

99212 (Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A problem focused history; A problem focused examination; Straightforward medical decision making … ) for the E/M.

• Modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) appended to 99212 to show that the E/M and injection were separate services.

Dx coding: Choose one of the following ICD-10 codes for the patient’s CTS, depending on encounter specifics:

• G56.00 — Carpal tunnel syndrome, unspecified upper limb
• G56.01 — … right upper limb
• G56.02 — … left upper limb.

Remember: If the provider has treated the patient’s CTS in the past with more conservative treatments before deciding on the injection, make sure that is noted on the claim. More conservative treatments could include nighttime wrist splinting, weekly physical therapy sessions, strength and stretching regimens, or steroid therapy.