Anesthesia Coding Alert

The most common diagnosis code for fibromyalgia is ICD-9 729.1 (Other disorders of soft tissues; myalgia and myositis, unspecified). The definition includes fibro-myositis (inflamed fibromuscular tissue), myalgia and myositis. Fibromyalgia is difficult to diagnose because its symptoms mimic those of other disorders. Franz Ritucci, MD, DABAM, FAEP, director of the American Academy of Ambulatory Care in Orlando, Fla., says that diagnosing fibromyalgia is frustrating for the physician and patient. "The diagnosis is one of exclusion. There is no single lab test that can establish a diagnosis of fibromyalgia; rather, exhaustive testing is performed to rule out other causes of diffuse musculoskeletal pain, such as polymyalgia rheumatica, Parkinson syndrome, or endocrine disorders."
 
In 1990, the American College of Rheumatology (ACR) established guidelines to aid physicians in diagnosing fibromyalgia. These include:

  a history of widespread pain of three months or longer; widespread pain is defined as pain on both the right and left sides of the body

  pain to palpation in 11 or more of 18 specified tender points.
Ritucci notes that the locations of tender points are remarkably consistent from patient to patient. "This consistency is helpful in diagnosis."
 
According to James Mallow, MD, an anesthesiologist and pain management physician in Leawood, Kan., other symptoms include sleep disturbance, fatigue, stiffness, skin fold tenderness, and cold intolerance. Mallow also notes that a common misdiagnosis is myofascial syndrome. "The difference is that myofascial syndrome is a local regional problem, whereas fibromyalgia is widespread."
E/M Services
Susan West, RHIT, coding consultant with Auditing for Compliance and Education Inc. (ACE) of Leawood, Kan., reminds coders that the appropriate E/M code depends on three key elements: history, exam and medical decision-making. "For an initial visit, the physician should use the E/M code which best reflects the level of evaluation and management provided," West says. For a patient who presents with symptoms of fibromyalgia, this may mean using a higher-level E/M code, such as 99203 or 99204.
 
If another physician requests an opinion or advice on the patient's evaluation and/or management and a consulting physician performs the E/M, Ritucci says, 99244 (office consultation) might be appropriate. "In this instance, the physician has probably spent 60 minutes face-to-face with the patient and/or the patient's family." Ritucci stresses that physicians should have adequate documentation to substantiate their choice of E/M code.
Testing for Exclusion, then Diagnosis
Extensive diagnostic tests may be performed by the pain management physician. Mallow notes that two of the most useful tests involve measuring the erythrocyte sedimentation rate (ESR) and the level of serum creatine kinase. Codes for these procedures are:

  82550 Creatine kinases (CK), (CPK); total
  82552 ... isoenzymes
  82553 ... MB fraction only
  82554 ... isoforms
  85651 Sedimentation rate, erythrocyte; non-automated
  85652 automated.
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