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Anesthesia Coding Alert

Reader Questions:

Never Guess at a Diagnosis

Published on Tue Feb 02, 2010

Question: My pain management specialist had a patient present with severe, chronic pain in the right side of her back. He performed an examination and administered two trigger point injections in the right lumbar multifidus muscle. I reported 20552 with one unit of service. The only notes he included in the patient's chart, however, were "the patient is experiencing back pain." He's done this before and diagnosed myofascial pain. Should I just code the diagnosis this way, since I'm pretty sure that's what he meant? Vermont Subscriber Answer: Without a clear, documented diagnosis you cannot code myofascial pain (729.1, Myalgia and myositis, unspecified). If you go ahead and code a diagnosis on an assumption, you're opening the door to trouble if a payer audit occurs. Here's why: The HIPAA-mandated ICD-9 Guidelines state: "List first the ICD-9-CM code for the diagnosis, condition, problem, or other reason for encounter/visit shown in the [...]
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