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Eli's Rehab Report

Symptoms and Testing Go Hand in Hand With Pain Therapy

Published on Fri Feb 01, 2002

Physiatrists often diagnose carpal tunnel syndrome (CTS, 354.0), de Quervain's disease (727.04), Raynaud's syndrome (443.0) or bursitis (726.4) for patients with pain in their hands or wrists. Patients who initially present with headache (ICD-9 784.0 ) or neck pain (723.1) are sometimes diagnosed with one of these disorders, as well.
 
Most patients with these disorders are treated with a combination of pain management injections, hand therapy and other nonsurgical procedures, with special care taken to ensure that diagnostic procedures and therapies can be performed together.
 
Coders can meet the challenge of billing tests for any of these disorders by knowing 1) what constitutes a simple test that should be counted as part of an E/M visit and 2) what types of tests should be coded with codes for the patient's symptoms.

Distinguishing Conditions

"We have had patients present to our practice who say the reason for their visit is CTS," says Christian Thorpe, billing and coding manager at Capitol Spine and Sports in Trenton, N.J. "The doctor sees them and determines that they have something completely different. They don't realize that many tests are performed to confirm carpal tunnel and every other condition. It's not just a summary of the symptoms and a set diagnosis."
 
Patients with hand and wrist pain will visit with the physiatrist for a standard E/M visit (99201-99215), and if the patient seems to demonstrate symptoms of CTS, the physiatrist will perform specific tests to determine if this is the case. "When I used to work at a rehab facility, we would get charts back saying that the physiatrist or therapist tested for Tinel's, Phalen's, or Finkelstein's,"  Thorpe says. "Some coders think that these 'tests' should  bring in extra money, but they're actually just part of the E/M visit."
 
Tinel's sign is a tingling that patients may experience when the physician taps on the median nerve. In the Phalen's test, the patient rests the elbows on a table and lets the wrists dangle with the backs of the hands pressed together, which can prompt CTS symptoms. In the Finkelstein's test, the practitioner has the patient put additional pressure on his or her thumbs to differentiate between CTS and de Quervain's disease. "Just because a test has a name attached to it doesn't necessarily mean it should be billed as anything but part of the physical exam," Thorpe says.
 
Although these tests are built into the fee for the E/M visit, physiatrists perform other tests to pinpoint the exact condition that the patient has, and these tests may be billed separately. For example, a physiatrist who suspects that a patient has osteoarthritis of the wrist (715.03) rather than CTS will take an x-ray (73115, radiologic examination, wrist, arthrography, radiological supervision and interpretation) to examine the patient's bones.
 
Physiatrists more often use electromyography (EMG, 95860-95872) or nerve conduction studies (95900-95904) to diagnose hand-related disorders. Remember that codes for nerve conduction studies are bilateral-exempt; that is, 95900 (nerve conduction, amplitude and latency/velocity study, each nerve; motor, without F-wave study) cannot be listed with modifier -50 (bilateral procedure) to indicate that both hands were tested. Code each entry on a separate line: 95900 with modifier -RT (right side), and 95900 with modifier -LT (left side).
 
Contrary to what many coders believe, EMG tests and nerve conduction studies can be billed on the same day for the same patient if both tests are medically necessary.
 
Note: Most Medicare carriers require that a physician evaluate extremity muscles innervated by three nerves (e.g., radial, ulnar, median) or four spinal levels and study at least five muscles before billing 95860-95864. No matter how many muscles are tested during the EMG, only one unit of service should be billed per extremity.

Code for Tests Using Symptoms

Practices should never link a nerve conduction study or EMG procedure code to the CTS code without proof, Thorpe says. "If you're 99 percent sure that the patient has CTS but you're performing the EMG or nerve conduction study to confirm that diagnosis, you still can't use the CTS diagnosis code on your claim because you don't have proof." Instead, code using the symptoms that prompted the patient to present to the practice. Common acceptable diagnoses for billing EMGs and nerve conduction studies include 719.44 (pain in hand), 726.4 (enthesopathy of wrist and carpus), 782.0 (disturbance of skin sensation) and 782.3 (edema).

Hand Therapy

Following a diagnosis of CTS, de Quervain's disease or other hand or wrist disorder, physiatrists usually work closely with therapists to ensure that the patient receives the appropriate exercises to help heal the hand without further damage.
 
"As a therapist, I would start the patient with education about resting the wrist, modifying the way they do their work or daily activities that may be contributing to the symptoms, provide splinting, and explain the wearing schedule and provide gentle range-of-motion exercise," says Laureen Jandroep, OTR, CPC, CCS-P, CPC-H, owner and CPC trainer for A+ Medical Management and Education in Absecon, N.J.
 
In addition, Jandroep suggests that a therapist use hot packs (97010, application of a modality to one or more areas; hot or cold packs), paraffin baths (97018, ... paraffin bath) and whirlpools (97022, ...whirlpool) to relieve the patient's pain. Note that although a hot pack can be reimbursed when billed on its own, the hot-pack charge is denied when billed with any other CPT code because it is bundled into the CPT code, e.g., a hot-pack charge is denied if the hot pack is given on the same day as any other therapy.
 
Any splinting performed to immobilize the patient's wrist should be coded 29125 (application of short arm splint [forearm to hand]; static).
 
In addition to the physical therapy modalities, Jandroep says, patients with hand and wrist disorders can benefit from activities-of-daily-living training (97535, self-care/home management training [e.g., activities of daily living (ADL) and compensatory training, meal preparation, safety procedures, and instructions in use of assistive technology devices/adaptive equipment] direct one-on-one contact by provider, each 15 minutes). "Often the CTS is on the dominant side, and teaching the patient to do daily tasks with the nondominant hand using the affected hand as an assist is a good compensatory technique. OT will often have the patient simulate activities they do repetitively to try to find a new way of doing the task without aggravating the affected wrist."
 
For instance, a patient presents to a therapy practice with a diagnosed case of CTS in her right hand. She is a bookkeeper who uses her right hand to perform calculations during most of the day; at home, she feeds and dresses her infant using mainly her right hand.
 
The occupational therapist might have the patient work on a computer for 15 minutes to practice typing in a more appropriate position and have her work on punching numbers into the keyboard using her left hand. The therapist might also train the patient on assistive aids, such as a wrist rest and ergonomic keyboard. For another 15 minutes, the therapist and the patient may sit with a doll or mannequin to demonstrate how the patient can feed her baby using her left hand instead of her right and how to hold and pick up her baby without exerting as much strain on her right hand.
 
All of these instructions are considered ADL and would be coded as two units (total of 30 minutes) of 97535.

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