Recoup Reimbursement for Long-Term CTS Treatment
Published on Thu Mar 01, 2007
Documentation is the key to success When a patient's carpal tunnel syndrome (CTS) treatment stretches into extended care, don't let carriers- strict guidelines stop rightful reimbursement in its tracks. Train your providers to document medical necessity by carefully outlining the condition's progressive nature. Show Full Diagnosis to Get Off to a Good Start ICD-9 only includes one CTS diagnosis: 354.0 (Carpal tunnel syndrome). Having only one code would seem to make your job easy, but carrier policies complicate your situation.
Roadblock: 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.
-Usually, proving medical necessity of an injection is not as difficult as proving the medical necessity of more invasive surgical procedures,- says Myriam Nieves, CPC, ACS-PM, owner of the consulting firm Precision Medical Systems in Ft. Lauderdale, Fla.
Injection necessity: 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.
Surgical proof: 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 neuroelectrodiagnostic test results (such as electromyography [EMG] or nerve conduction studies). Inflammation caused by arthritis, pregnancy, obesity, hypothyroidism, repetitive motion disorder (RMD) and diabetes can lead to CTS, says Tonia Raley, CPC, claims processing manager for Medical Information Systems in Phoenix. Review Carrier Policies for Nonsurgical Treatments Physicians use a variety of noninvasive treatments for patients in the early stages of CTS.
-Depending on the severity of the condition, treatment may be conservative,- Raley says. Initial treatment can include having the patient change activities, wear a soft splint, undergo physical therapy and/or take anti-inflammatory medications.
Next step: If the patient fails to respond to these more conservative treatments, your physician might administer injections to relieve the patient's discomfort, such as 20526 (Injection, therapeutic [e.g., local anesthetic, cortico-steroid], carpal tunnel).
Watch out: Many providers relied on 20605 (Arthrocentesis, aspiration and/or injection; intermediate joint or bursa [e.g., temporomandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa]) to report a carpal tunnel injection before CPT introduced 20526 a few years ago. Now 20526 is a more accurate code in most circumstances.
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.
-I was only able to find one carrier (Unicare) that required at least four weeks of splinting [...]
