Neurology & Pain Management Coding Alert

If carpal tunnel syndrome (CTS) is suspected but not confirmed, neurologists may use signs and symptoms, pain, and other ICD-9 codes to support medically justified testing and arrive at a definitive diagnosis. This approach avoids labeling the patient with an unconfirmed diagnosis, prevents unwarranted procedures and ensures maximum ethical reimbursement for the treating physician. If a definitive diagnosis is reached, however, the most specific ICD-9 code (i.e., 354.0 -- carpal tunnel syndrome) must be reported.
Defining CTS  
CTS is the most frequently diagnosed compression syndrome of the upper extremities and occurs when the median nerve becomes entrapped as it passes through the space formed by the carpal bones and the flexor retinaculum (a band of connective tissue) in the wrist. The syndrome is often associated with work-related repetitive or cumulative trauma but may be caused by fracture, arthritis, tumor, infection, systematic conditions (e.g., obesity, diabetes mellitus, pregnancy, etc.) and others. Patients suffering from CTS most often complain of numbness, paresthesia (a burning or tingling sensation) and pain in the affected hand(s) and wrist(s), which may appear at night.
Provide Medical Necessity for Diagnostic Testing  
The most common diagnostic tests for CTS are electromyograms (EMG) and nerve conduction studies (NCS). Documentation is essential when billing these tests. Do not use a "rule-out" diagnosis of 354.0 to substantiate medical necessity -- this unfairly labels the patient as suffering from a condition that he or she may not have. Also, insurers do not accept rule-out diagnoses to justify diagnostic testing.
 
If CTS is suspected, the physician should carefully note all signs and symptoms in the medical record, with evidence of associated problems, such as muscular atrophy, dryness and coldness near the wrist and decreased grip strength. If, after this initial evaluation, the neurologist still suspects CTS, an EMG or NCS may be ordered. Common acceptable diagnoses include 719.44 (pain in joint, hand), 726.4 (enthesopathy of wrist and carpus), 782.0 (disturbance of skin sensation) and 782.3 (edema), says Annette Grady, CPC, CPC-H, who works with three neurology group practices and is the coding and reimbursement coordinator for the Bone & Joint Center in Bismark, N.D.
 
If they are present and substantiated, the neurologist may also report disease and injury diagnoses. For example, arthritis may cause swelling and pressure on the median nerve and develop into CTS. Arthritis codes include 714.0 (rheumatoid arthritis), 715.94 (osteoarthrosis, unspecified whether generalized or localized, hand), 723.4 (brachial neuritis or radiculitis NOS), 727.04 (radial styloid tenosynovitis), 727.41 (ganglion of joint) and 728.6 (contracture of palmar fascia). Injury codes include 955.1 (injury to peripheral nerve[s] of shoulder girdle and upper limb, median nerve) and 955.2 (... ulnar nerve).
 
"The more information you can provide, the less likely the insurer is to reject the claim," [...]