Radiology Coding Alert

Watch for inconsistencies in injection guidance coding requirements.

Coding for whiplash diagnosis and treatment is usually pretty straightforward. Watch for times to take extra care, however, especially if the patient's symptoms persist despite conservative therapy and warrant more extensive treatment.

Watch for Move From Therapy to Scans

When a patient presents with whiplash symptoms, the treating physician will often order neck X-rays, such as 70360 (Radiologic examination; neck, soft tissue).

Once the patient has a confirmed diagnosis of whiplash (847.0, Sprains and strains of other and unspecified parts of back; neck sprain), the treating physician typically will prescribe conservative treatment. Common options include physical therapy, nonsteroidal anti-inflammatory drugs (NSAIDs), and muscle relaxants. Some patients also may benefit from wearing a soft cervical collar or by using a portable traction device.

If conservative treatment fails, the physician might order additional diagnostic imaging tests. These could include:

• CT scans, such as 70490 (Computed tomography, soft tissue neck; without contrast material), 70491 (... with contrast material[s]), and 70492 (... without contrast material followed by contrast material[s] and further sections)
• MRI scans, such as 70540 (Magnetic resonance [e.g., proton] imaging, orbit, face and/or neck; without contrast material[s]), 70542 (... with contrast material[s]), and 70543 (... without contrast material[s], followed by contrast material[s] and further sequences).

Count Trigger Point Injections Correctly

If the patient's pain continues, he may see your interventional pain specialist for trigger point injections to relieve painand muscle tenderness. Code these procedures with 20552 (Injection[s]; single or multiple trigger point[s], 1 or 2 muscle[s]) or 20553 (...single or multiple trigger point[s], three or more muscles).

Caution: The difference between the two codes is the number of muscles the physician injects, not the number of trigger points or  the number of injections he administers, says Marvel J. Hammer, RN, CPC, CHCO, president of MJH Consulting in Denver. The descriptors clarify that if your provider documents a different muscle, you should count the number of muscles to determine the difference between 20552 and 20553. If, however, the provider injects multiple trigger points within the same muscle, you only count one muscle, regardless of the amount of injections.

Watch point: Because of the "one or two muscles" and "three or more muscles" distinction between codes, you'll report a maximum of one unit for either 20552 or 20553 for an encounter -- not both codes. For example, if your pain management physician injects trigger points in a total of four separate muscles, compliant coding would be one unit of 20553.

Also remember to report the appropriate radiological guidance code. Options include:

• 76942, Ultrasonic guidance for needle placement ...
• 77002, Fluoroscopic guidance for needle placement ...
• 77021, Magnetic resonance guidance for needle placement ....

Move to Nerve Blocks for More Pain Relief

When more conservative treatments for whiplash don't help the patient enough, your physician might administer nerve blocks to help diagnose a patient's condition and/or provide therapeutic pain relief. Common options include lidocaine and/or steroids such as methylprednisolone acetate (J1020, Injection, methylprednisolone acetate, 20 mg) into cervical facet joints (such as C3-4 and C4-5).

Code it: Report the block at the first facet joint level with 64490 (Injection[s], diagnostic or therapeutic agent, paravertebral facet [zygapophyseal] joint [or nerves innervating that joint] with image guidance [fluoroscopy or CT], cervical or thoracic; single level).

Submit blocks at additional facet joint levels on the following lines of your claim with +64491 (... second level [List separately in addition to code for primary procedure]) and +64492 (... third and any additional level[s] [List separately in addition to code for primary procedure]) as appropriate.

Guidance: Physicians use imaging guidance to helpensure they inject the correct site. In previous years, you reported guidance in addition to the injection procedure code. CPT® 2010 introduced codes 64490-+64492, which include fluoroscopic or CT guidance. In other words, you should not report CT or fluoro guidance separately for these services. On the other hand, if ultrasound guidance is used, report 0213T-0215T (Injection[s], diagnostic or therapeutic agent, paravertebral facet [zygapophyseal] joint [or nerves innervating that joint] with ultrasound guidance, cervical or thoracic ...).

Bilateral question: Providers often administer facet joint injections unilaterally. If your physician administers bilateral injections, remember to append modifier 50 (Bilateral procedure) to the injection code(s).

Certain factors (age, gender, and pre-existing conditions like arthritis) can influence the severity and prognosis of whiplash injuries. When the patient does not respond to more conservative treatments or if her symptoms worsen, a physician may re-evaluate her for other disorders. In these instances, it may be appropriate to code the additional diagnoses along with whiplash. These diagnoses can help justify greater pain management intervention (such as cervical epidurals, facet blocks, or even referral to surgery).

Example: A physician might determine that the patient's presenting symptoms and/or test results indicate occipital neuralgia (723.8, Other syndromes affecting cervical region), spondylosis (721.0, Cervical spondylosis without myelopathy), or herniated disc (722.0, Displacement of cervical intervertebral disc without myelopathy).

Rely on Nerve Destruction as Last Recourse

If nerve blocks do not bring the patient long-lasting relief, a physician may consider paravertebral facet joint denervation.

Document it: Before taking the patient's treatment to this level, the physician should have thorough documentation of other treatments. The patient's chart should include two important details:

• The appropriate diagnostic paravertebral facet joint block or medial branch nerve block studies that identify the specific joint level
• Documentation that the patient had significant -- but not long-lasting -- pain relief from the facet joint blocks.

Some payers are beginning to require actual documentation and quantification of the patient's status, Hammer says. For example, the payer might want details regarding the percentage of change in pain, duration of pain relief, and changes in the patient's functional status during relief from the diagnostic blocks.

If the patient meets these criteria, the physician may use paravertebral facet joint denervation to treat back or neck painfollowing whiplash/post-traumatic injury and to relieve the pain of associated cervicogenic headache.

CPT® includes two codes for denervation in these cases:

• 64626 -- Destruction by neurolytic agent, paravertebral facet joint nerve; cervical or thoracic, single level
• +64627 -- ... each additional level (list separately in addition to code for primary procedure).

As with nerve blocks, physicians often perform the therapeutic destructive procedures as unilateral procedures. If the specialist performs a bilateral procedure, append modifier 50 and document which joint levels he treated. A parenthetical note preceding 64622 instructs you to use 77003 (Fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures [epidural, subarachnoid, or sacroiliac joint], including neurolytic agent destruction) for fluoroscopic guidance and needle localization performed together with 64622-64627.

Smart move: With the prevalence of whiplash injury and the range of treatment options for whiplash and related disorders, physicians and coders need to know what payers cover -- and what they don't. Whiplash may be denied for thirdparty coverage because it often results from an auto accident. Confirm which payer will be responsible for payment prior to performing any diagnostic tests and therapeutic procedures.