Radiology Coding Alert

Set your sights beyond 724.5 -- sometimes.

Your interventional radiologist may be seeing more patients complaining of chronic pain. Trouble arises when you don't see documentation of a definitive diagnosis for the visit. You know better than to alter or guess a diagnosis to ensure payment; now learn about appropriate codes that can help you handle the situation.

Clue In to Why Specificity Matters

Specificity in diagnosis coding is always important, but it is increasingly vital because "third party payers are establishing more stringent coverage criteria for therapies and procedures and are using automated edits to deny claims based on the lack of a covered diagnosis," says Mary H. McDermott, MBA, CPC, with Johns Hopkins University in Baltimore.

"Using a non-specific diagnosis code which may be 'close' -- but not exact -- may mean you won't be paid for a service due to a Medicare Local Coverage Determination [LCD] or a third-party medical policy," McDermott points out. Opting for less specific codes also might mean you receive payment for a service that would not be covered under the correct diagnosis.

Both of these scenarios present different problems. Using the most specific appropriate diagnosis for the patient and making sure it is well documented in the medical record will help ensure appropriate reimbursement for the provider and appropriate coverage for the patient.

Reality: "Using the incorrect diagnosis may limit coverage or may get you paid for services that are not covered, which increases your risk during audit," McDermott says.

1: Tackle Vague TPI Diagnosis

Consider the following scenario and how you would select a diagnosis.

Scenario: Patient A presents at your office for treatment of severe, chronic pain in the right side of his back. The pain began about ten months ago. Your interventional radiologist uses ultrasound guidance to administer two trigger point injections (TPIs) in the right lumbar multifidus muscle for pain relief. However, his chart notes say only that the patient had "back pain."

The chart: You receive the chart and also see your radiologist performed trigger point injections on other patients in the past, using 20552 (Injection[s]; single or multiple trigger point[s], 1 or 2 muscle[s]) and 76942 (Ultrasonic guidance for needle placement ...). The most recent injections performed on the other patients' backs were for myofascial pain.

In the absence of a more specific diagnosis, should you assume that Patient A also has myofascial pain, and report one unit (because trigger point injection coding is based on the number of separate muscles injected and not the quantity of injections performed) of 20552 with a diagnosis of 729.1 (Myalgia and myositis, unspecified)?

Answer: No. Making assumptions doesn't support compliant coding. "From a clinical standpoint, pain can be caused by a myriad of reasons," explains Leslie Johnson, CCS-P, CPC, director of coding and education for Medi-Corp, Inc., in Cranford, N.J. "Coders aren't clinicians and shouldn't make presumptions, even if the diagnosis seems evident."

If your radiologist did not specifically document myofascial pain or myalgia and you use one of those codes, you could find yourself in trouble in the event of a payer audit. Such errors are exactly the kind of thing that auditors keep an eye out for. Instead, you may need to report an unspecified code, such as 724.5 (Backache, unspecified).

LCD check: Payers may not always accept "unspecified" codes in support of a service, but some payers will reimburse for 724.5 for trigger point injections. So be sure to study your payer coverage policies carefully before determining if the diagnosis fits the payer's rules. "A coder needs to be aware of the payer policies and LCDs to be able to relay that information to the physician," Johnson says.

Remember, accurate coding requires that you choose the code based on the documentation " you must never report a diagnosis code simply because you know the payer will reimburse the service if you report that diagnosis.

2: Watch for Documented Connection to Prior Problem

Prior conditions can contribute to current complaints. When faced with that situation, your physician should document " and you should code " the prior conditions if they affect management of the current condition.

Example: "Prior trauma, such as a previously broken bone, can cause patients to experience back or neck pain," McDermott says. "If a patient's pain stems from a previous condition, that diagnosis can also be coded to justify these diagnostic/therapeutic procedures."

Depending on the circumstances, you might be able to report a late effect code to show the causal effect or a V code to report a personal history of trauma. In a situation where chronic neck pain was present due to a prior traumatic vertebral fracture -- at C2-C3, for example -- you could code this as:

• 338.21 " Chronic pain due to trauma
• 723.1 " Cervicalgia
• 905.1 (Late effect of fracture of spine and trunk without mention of spinal cord lesion) or V15.51 (Other personal history presenting hazards to health; traumatic fracture).

Your coding might be different for a pathologic fracture, such as 338.21, 723.1, and V13.51 (Personal history of other diseases; pathologic fracture). "The key to the correct coding of these contributory conditions is making sure they are appropriately documented in the medical record," McDermott emphasizes.

3: Dig Deeper for Comprehensive Diagnosis

Scenario: Patient B comes to your facility complaining of chronic pain in her lower back and right thigh. Your radiologist provides a facet joint nerve block at L4/L5 and writes "lumbar, thigh pain" on Patient B's chart.

You read the chart and look up the code for facet joint injection (64493, Injection[s], diagnostic or therapeutic agent, paravertebral facet [zygapophyseal] joint [or nerves innervating that joint] with image guidance [fluoroscopy or CT], lumbar or sacral; single level). But when you check the approved diagnoses, neither lumbar pain nor thigh (limb) pain is listed as acceptable. What's your next step?

Answer: Check with your radiologist to verify Patient B's condition. Often, you will learn the patient has a more comprehensive problem, such as 721.3 (Lumbosacral spondylosis without myelopathy).

In that case, after your provider documents the spondylosis as a correction or addendum, only code the patient's main condition, 721.3. You should not additionally report the patient's pain symptoms. The ICD-9 official guidelines instruct coders that "Signs and symptoms that are associated routinely with a disease process should not be assigned as additional codes, unless otherwise instructed by the classification."