Anesthesia Coding Alert

When reporting extended treatment for carpal tunnel syndrome (CTS), make sure you document the treatment's medical necessity by carefully outlining its progressive nature. Pain management physicians and their coders can become frustrated when seeking appropriate reimbursement for treating CTS (354.0), even though it is one of the most frequently diagnosed upper-extremity compression syndromes. Medicare and other insurers can be very strict when processing claims for CTS, especially when conservative therapy methods have failed and the patient receives more extensive treatment.

Insurers can be cautious with claims involving treatment for CTS, says Linda Runfola, CPC, a consultant with NAPA Management Services in Syracuse, N.Y. "A diagnosis of CTS in itself is not enough to justify all forms of treatment. The physician must document the medical necessity of treatment performed and demonstrate that previous treatment modalities have failed to alleviate the symptoms of CTS."

CTS occurs when the flexor tendons in the wrist become enlarged, often due to inflammation, and increase pressure in the carpal tunnel. Because the bones and transverse carpal ligament in the carpal tunnel are not able to stretch in response to the increased pressure, they compress the median nerve that also runs through the carpal tunnel. CTS symptoms include burning, tingling numbness in the fingers, especially the thumb and index and middle fingers, difficulty gripping or making a fist, and inability to hold on to objects. Pain associated with CTS often flares at night. Although physicians sometimes label CTS as a repetitive-stress injury (RSI), it can also result from inflammation caused by arthritis, pregnancy, obesity and diabetes. Review Carrier Policies for Nonsurgical Treatments In the early stages of CTS, patients are treated with a variety of noninvasive methods, including physical therapy, orthopedic braces that keep the wrist in a neutral position, and anti-inflammatory medications. If the patient fails to respond to these more conservative treatments, the pain management physician may administer injections (e.g., 20605*, Arthrocentesis, aspiration and/or injection; intermediate joint, bursa or ganglion cyst [e.g., temporo-mandibular, acromioclavicular, wrist, elbow or ankle, olecranon bursa]) to relieve discomfort.

As part of its review policy, Cahaba Government Benefits Administrators, Medicare's Fiscal Intermediary for Iowa and South Dakota, notes that "injection of a carpal tunnel is indicated for the patient with a mild case of carpal tunnel syndrome if oral NSAIDs and splinting have failed." Its policy lists these covered codes:
20526 Injection, therapeutic (e.g., local anesthetic, corticosteroid), carpal tunnel
20550* Injection; tendon sheath, ligament, ganglion cyst
20551 Injection; tendon origin/insertion. Many carriers, like Cahaba, will reimburse separately for the cost of the drug the physician uses in these injections. Carriers may have limits on the number of injections they cover. For example, Cahaba's policy notes that the clinical [...]