Eli's Rehab Report

Use the 337.2x series only if the physiatrist definitively diagnoses RSD

If your physiatrist suspects that a patient has reflex sympathetic dystrophy (RSD), you should report symptoms until testing reveals a definitive diagnosis.

Because diagnosing RSD can require more than one simple test, your PM&R practice should nail down the RSD diagnosis coding rules to justify medical necessity for diagnostic tests, treatment procedures and post-treatment visits. And contrary to popular belief, this may mean that you report a diagnosis code other than the 337.2x series for some RSD-related visits.

The following expert tips can help your practice collect reimbursement for RSD treatment every time.

"The most important RSD rule is that you should not bill an RSD diagnosis code (337.20-337.22, 337.29) until testing reveals a definitive diagnosis. Until then, you should code the signs and symptoms instead," says Trish Bukauskas-Vollmer, CPC, owner of TB Consulting in Myrtle Beach, S.C.

Physiatrists find diagnosing RSD particularly difficult because the patient may exhibit symptoms one hour but not the next. Therefore, the physiatrist must take a careful and detailed history of the possible signs. The E/M visit (99201-99205 for new patients, 99211-99215 for established patients) is the first step to diagnosis. The following outlines the most common diagnoses that PM&R practices see during the three RSD stages:

Stage-1 symptoms: Prolonged pain, sensitivity to temperature, sensitivity to light touch (ICD-9 782.0 , Disturbance; touch), severe (usually a burning-type) pain, skin color changes (generally a loss of color so the skin appears almost white), swelling and redness (common in cases that are vascular in origin).

Stage-2 symptoms: The affected area becomes discolored, cold and painful. Osteoporosis (733.0x) and joint stiffness (719.5x) can develop at this stage.

Stage-3 symptoms: Muscles and tendons waste away, including contracture and withering of the affected limb. This is represented by diagnosis codes such as 728.2 (Muscular wasting and disuse atrophy, not elsewhere classified).

If the patient has severe pain, the physiatrist may administer a nerve block on the same day as an E/M visit to alleviate the patient's pain until the physiatrist can establish a definitive diagnosis and begin treatment.

Because some insurance policies don't pay for the pre-and postprocedure E/M component but will pay for a separate and significant E/M, you should report the appropriate E/M code (such as 99203) appended with modifier -25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service), followed by the nerve block code (64400-64484).

If a physician refers a patient to you and asks you to take over the patient's RSD care, you cannot report a consult because coding experts and insurers consider this a transfer of care. If the physician sends the patient to you, asks you to run tests and report back to him, however, you can probably report a consult (99241-99245).

Example: Aprimary-care physician (PCP) refers a patient whose test results indicate RSD. The physiatrist performs a new patient E/M visit (99203) as well as a nerve block (64400-64484). This would not be a consult because the referring physician wants you to treat the patient for a previously diagnosed condition.

Physiatrists normally perform physiological tests to diagnose RSD. These tests measure the interactions within the patient's body. The most common of these for diagnosing RSD include thermogram (infrared imaging), the acetone drop test, and a tri-phase bone scan.

Thermography (93740, 93760 and 93762) measures the temperature on and beneath the patient's skin. The acetone drop test (82010, Acetone or other ketone bodies, serum; quantitative) tests allodynia or pain from light touch. An RSD patient may have cold hyperalgesia (782.0,Disturbance of skin sensation) during this test.

A tri-phase bone scan (78315, Bone and/or joint imaging; three phase study) shows increased blood uptake in the injured limb compared to the healthy limb. This test can assess the stage of RSD and rule out other problems like neoplasms or osteomyelitis.

After the physiatrist definitively diagnoses RSD, you should report 337.20 (Unspecified RSD), 337.21 (RSD of the upper limb), 337.22 (RSD of the lower limb) or 337.29 (RSD of other specified site). The usual RSD causes, such as injury or trauma, may warrant an E or V code following the other diagnosis.

Example: If a patient has RSD due to a trauma from falling off a ladder, list the RSD diagnosis (337.20-337.29) and then the appropriate E code to describe the ladder fall (E881.0).

"As coders, you tell a story," says Anita Carter, LPN, CPC, of APlus Medical Management & Education in Absecon, N.J. "If a patient has RSD due to trauma, then by all means, include it."

If RSD follows a fracture, trauma or other injury, you can code the appropriate "late effects" code (905.x, Late effects of musculoskeletal and connective tissue injuries).

After the physiatrist controls the patient's RSD, he begins to treat the original underlying problem or coexisting condition. Coexisting conditions may include nerve entrapment (355.9, Mononeuritis of unspecified site), peripheral neuropathies (356.9, Hereditary and idiopathic peripheral neuropathy; unspecified), carpal tunnel syndrome (354.0), tarsal tunnel syndrome (355.5), and thoracic outlet syndrome (353.0).

Tip: When you code the underlying problem, you should always list the diagnosis that the physiatrist actually treats in the first position.

Example: An RSD patient returns after two years of treatment and is doing well. The physician treats carpal tunnel syndrome, the underlying problem. You should report carpal tunnel syndrome (354.0) as your diagnosis.

Note: See our article "1 Sure Way to Nail Down the Correct RSD Codes" on page 53 for more information on selecting RSD treatment codes.