Orthopedic Coding Alert

You won’t find specific guidelines for moving to the next treatment level.

When a patient’s carpal tunnel syndrome (CTS) treatment stretches into extended care, don’t let payers’ strict guidelines stop rightful reimbursement in its tracks. 

Good idea: Train your providers to document medical necessity by carefully outlining the condition’s progressive nature.

Question 1: True/False - Treatments Are of Only 1 Variety

Answer: False. 

Physician use a range of treatments for CTS patients. Ultimately non-invasive treatments can become invasive when the non-invasive treatments are nonresponsive.

Depending on the severity of the condition, initial treatment may be conservative. It can include having the patient change activities, wear a soft splint, undergo physical therapy or take anti-inflammatory medications.

If the patient fails to respond to these more conservative treatments, however, your physician might administer injections to relieve the patient’s discomfort, such as 20526 (Injection, therapeutic [e.g., local anesthetic, cortico-steroid], carpal tunnel), says Marvel Hammer, RN, CPC, CCS-P, ACS-PM, CPCO, owner of MJH Consulting in Denver, Colo.

Problem: Carriers expect physicians to try nonsurgical, conservative treatments first, but most policies don’t outline specific guidelines for when your physician should move to the next treatment level.

Question 2: True/False - Injections? You May Need a Bilateral Mod

Answer: True. 

If your orthopedic surgeon injects both of the patient’s wrists during CTS treatment, you’ll need to report it as a bilateral procedure. You can do this with either modifier 50 (Bilateral procedure) or modifiers LT (Left side) and RT (Right side).

If you report modifier 50, simply append it to the injection code for most carriers. If your carrier prefers modifiers LT and RT, report the injection code as two line items (one with LT and one with RT). Check your carrier’s guidelines to verify its preference.

Note: Physicians may administer bilateral carpal tunnel injections if the patient has symptoms in both hands or administer the injections along with another service during the patient’s visit. When that’s the case, be sure to submit the appropriate modifiers with your claim.

Question 3: True/False - You Can Always Report Additional Services 

Answer: False.

Orthopedists often perform other services when a patient comes for an injection — but that doesn’t mean you can always code it separately. You may report an E/M code in addition to the CTS injection codes only if the E/M service is significant and separately identifiable from the injection procedure.

Example: The patient comes to your office for a CTS injection and also complains to the doctor that he has knee pain. Your physician can complete an E/M service to check the knee problem and bill for it. Remember: This still needs to be significant. The visit can’t be an incidental “oh, by the way, I have knee pain.” The visit should be at least a level III. Some people use “significant” to mean that the E/M code has a higher RVU than the procedure (injection) code; in some cases, that needs a level IV E/M code. 

When the additional service qualifies for an E/M code, append it with modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service).

Caution: If the injection is the primary reason your physician sees the patient, you should report only the injection service. For instance, if the doctor has already decided to administer a CTS injection and wants to evaluate the patient prior to the procedure, you cannot report the evaluation as a separate, billable service.

Question 4: True/False - Surgeries Don’t Require Pre-Authorization

Answer: False. 

Because surgery is a last-resort treatment for CTS, many coders recommend that you obtain preauthorization to determine your carrier’s coverage limitations. Preauthorization establishes medical necessity of the planned treatment. Coverage limitations are a separate issue requiring a separate phone call.

“As with any other procedure, always make sure that the patient’s plan covers the service and that there are not any pre-existing conditions or medical necessity issues that might prevent the claim from being paid” (such as a fractured wrist unrelated to work that caused the problem), says Barbara J. Cobuzzi, MBA, CENTC, CPC-H, CPC-P, CPC-I, CHCC, president of CRN Healthcare Solutions, a consulting firm in Tinton Falls, N.J.

The most common approaches to relieve the pressure are open or endoscopic procedures for carpal tunnel release. Physicians once opted for open procedures as the norm, but the patient had a longer, more painful recovery. Endoscopic release techniques may shorten the patient’s recovery period but have had more reported complications. CPT® includes two codes related to surgical treatment of CTS:

• 29848 (Endoscopy, wrist, surgical, with release of transverse carpal ligament), for an endoscopic approach
• 64721 (Neuroplasty and/or transposition; median nerve at carpal tunnel), for an open approach.

Question 5: True/False - One ICD-9 Code Doesn’t Make Dx Coding Easy

Answer: True. 

You may know ICD-9 only includes one CTS diagnosis: 354.0 (Carpal tunnel syndrome). Think that means your job is easy? Not so. Carrier policies complicate your situation. In other words, a stand-alone diagnosis of CTS doesn’t justify all forms of treatment in some carriers’ eyes. The ease of proving medical necessity depends partly on the service your physician provides.

For instance, you’ll have less of a struggle justifying an injection than a more invasive procedure — but you still have to provide specific documentation. If your physician plans to administer an injection to treat a patient’s CTS, carriers may require documentation that the patient has changed or avoided activities that cause the CTS symptoms or that the patient needs to take frequent breaks from repetitive tasks. You might have documentation that the problem wakes the patient at night, which is universal for really affecting activities of daily living (sleeping).

On the other hand, before giving the go-ahead for open or endoscopic surgery to treat CTS, carriers might require documentation that NSAIDs, splints, and physical therapy have failed or are not otherwise indicated. The carrier might also require proof of abnormal electrodiagnostic test results (such as electromyography [EMG] or nerve conduction studies [NCV]). Inflammation caused by arthritis, pregnancy, obesity, hypothyroidism, repetitive motion disorder (RMD) and diabetes can lead to CTS.