Pain Management Coding Alert

Most insurers require a CTS diagnosis before approving therapeutic measures.

When you are coding for carpal tunnel syndrome (CTS) treatments, you have to know the answer to one question first: Has your PM provider confirmed that the patient has CTS?

Explanation: If you start coding for CTS treatments and tests without a confirmed CTS diagnosis, denials are likely headed your way. “Most insurance carriers do require a confirmed [CTS] diagnosis … for treatment, therapy, or surgery,” explains Lynn M. Anderanin, CPC, CPMA,CPPM, CPC-I, COSC, senior director of coding education at Healthcare Information Services in Park Ridge, Illinois.

Check out the most pressing issues you’ll need to address when coding for — or recognizing — services that confirm CTS.

Know CTS, Wrist Pain Difference

First, know that CTS and wrist/hand/finger pain are not interchangeable diagnoses, and wrist/hand/finger pain likely won’t pass as an acceptable diagnosis for CTS treatments. Symptoms for an M25.53- (Pain in wrist) or M25.54 (Pain in joints of hand) diagnosis are fairly straightforward: if the patient reports to the PM specialist complaining of pain in the wrist and/or finger joints, you can report an ICD-10 code from one of these sets.

To reach a diagnosis of CTS, however, the patient must be suffering from more than pain in the wrist/fingers. “CTS symptoms usually include numbness and tingling in your hand and fingers as well as weakness when picking things up,” Anderanin says.

When you do reach a CTS diagnosis, you’ll choose from one of the following codes, depending on the patient’s specific condition and what’s in the notes:

• G56.00 — Carpal tunnel syndrome, unspecified upper limb
• G56.01 — … right upper limb
• G56.02 — … left upper limb
• G56.03 — … bilateral upper limbs.

Getting to that diagnosis will likely involve more than just a standard office evaluation and management (E/M) service. You’ll need test results to confirm CTS — typically from one specific type of test.

EMG Marks Most CTS Confirmation Encounters

In Anderanin’s experience, a needle electromyography (EMG) is the test your provider will most likely perform to confirm CTS. There are other tests that some providers might use to confirm CTS, but we’ll stick with the EMG for the purposes of the following scenario:

Example: A primary care physician refers a patient to the PM specialist for treatment of right extremity pain. The patient has numbness and tingling in their right thumb and index finger, causing weakness and pain in their hand while typing on the computer after a short period of time. After a single-extremity needle EMG without related paraspinal areas, the provider confirms right-sided CTS. The provider injects 40 mg of Depo-Medrol into the affected area, and applies a wrist brace. The provider instructs the patient to return for a follow-up visit in four weeks to check the progress of CTS treatment.

For this encounter, the provider used an EMG, confirmed CTS, and then began therapy in the form of the injection and wrist brace application. You would code this encounter as follows:

• 95860 (Needle electromyography; 1 extremity with or without related paraspinal areas) for the EMG
• 20526 (Injection, therapeutic (eg, local anesthetic, corticosteroid), carpal tunnel) for the injection therapy
• J1030 (Injection, methylprednisolone acetate, 40 mg) for the Depo-Medrol supply
• L3908 (Wrist hand orthosis (WHO), wrist extension control cock-up, non molded, prefabricated, off-the-shelf) for the wrist brace application.

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