Neurology & Pain Management Coding Alert

Hint:  Focus on testing, diagnosis, and treatment.

A lack of definitive results from diagnostic tests can complicate carpal tunnel coding. Take care to not make haste to jump to a definitive diagnosis code. Yet, this does not mean you will compromise on payment. Follow these tips to ensure you earn what you should for carpal tunnel cases.

1. Don’t Jump to a Diagnosis Too Soon

When your neurologist treats carpal tunnel syndrome (CTS), you usually report diagnosis code 354.0 (Carpal tunnel syndrome).

Caution: Don’t slip and report 354.1 (Other lesion of median nerve) instead of CTS. The symptoms of the two conditions can be identical (numbness and pain in the thumb, index and middle fingers), but your neurologist needs to establish a certain diagnosis so you can code accurately. CTS is caused by the inflammation in the transverse carpal ligament, which then compresses the nerve and produces the symptoms. The difference here is that you report 354.1 for inflammation of the nerve itself and 354.0 (CTS) for the same symptoms in the ligament or surrounding tissues.

“Typically 354.1 would be coded if the median neuritis was in a location other than the wrist, i.e. inflammation or entrapment at the elbow,” says Marvel Hammer, RN, CPC, CCS-P, PCS, ACS-PM, CHCO, owner of MJH Consulting in Denver, CO.

“CTS is not the only disease process that can cause the symptoms generally associated with CTS,” explains Rena Hall, CPC, billing/insurance coordinator at Kansas City Neurosurgery Group in Missouri. Inflammation caused by arthritis, pregnancy, obesity, hypothyroidism, repetitive motion disorder (RMD), and diabetes can mimic symptoms of CTS.

Watch point: Your neurologist may document “suspected” CTS in the clinical record. If so, don’t report the definitive diagnosis code 354.0 just yet. While your neurologist is waiting for test results, you should report the patient’s symptoms in support of any services your physician provides.

Possible diagnosis codes for signs and symptoms could include:

• 729.5 (Pain in limb) for pain in the hand, wrist or forearm
• 782.0 (Disturbance of skin sensation) for the symptoms of tingling and numbness
• 728.87 (Muscle weakness [generalized]) for any weakness in the hand muscles
•  729.81 (Swelling of limb) for a feeling of a swollen hand
• 719.44 (Pain in joint, hand)
• 726.4 (Enthesopathy of wrist and carpus)
• 782.3 (Edema).

Reason: ICD-9 official guidelines instruct you to use signs and symptoms codes in the office setting when your neurologist documents an uncertain diagnosis. According to ICD-9, “Do not code diagnoses documented as “probable,” “suspected,” “questionable,” “rule out,” or “working diagnosis,” or other similar terms indicating uncertainty. Rather, code the condition(s) to the highest degree of certainty for that encounter/visit, such as symptoms, signs, abnormal test results, or other reason for the visit”.

You may find the ICD-9 guidelines on the CDC website: http://www.cdc.gov/nchs/icd/icd9cm_addenda_guidelines.htm#guidelines

2. Check for Diagnostic Testing

To establish a diagnosis of CTS, your neurologist may perform nerve conduction studies (NCS) and/or electromyography (EMG). Each one has its own diagnostic significance.

“EMGs are usually done for more proximal lesions,” says William J. Mallon, MD, medical director of Triangle Orthopaedic Associates in Durham, N.C. “NCSs are mostly done for CTS diagnosis. The EMG rules out other problems, such as cervical radiculopathy.”

Check number of limbs in EMG: Your neurologist may do the EMG in one or both upper limbs. You report code 95860 (Needle electromyography; 1 extremity with or without related paraspinal areas) for EMG in one limb and 95861 (Needle electromyography; 2 extremities with or without related paraspinal areas) for EMG in both upper limbs.

“You report 95860 or 95861 only when no NCS is performed,” says Hammer. “If both NCS & EMG are performed, then you need to look at either add-on code +95885 (Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited [List separately in addition to code for primary procedure]) or +95886 (Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels [List separately in addition to code for primary procedure]).”

Watch for the complete limb EMG. “Additionally, the 95860 (Needle electromyography; 1 extremity with or without related paraspinal areas) – 95864 (Needle electromyography; 4 extremities with or without related paraspinal areas) codes, as well as the 95886 code is ONLY billed when a complete limb EMG study has been performed – testing performed on ‘five or more muscles studied, innervated by three or more nerves or four or more spinal levels’  otherwise the code would be 95870 (Needle electromyography; limited study of muscles in 1 extremity or non-limb [axial] muscles [unilateral or bilateral], other than thoracic paraspinal, cranial nerve supplied muscles, or sphincters) if no NCS are performed.”

“When you code an EMG that your neurologist performs to diagnose or monitor carpal tunnel, you must be sure to choose the EMG code that properly reflects the number of limbs the neurologist stimulates,” says Jayne Bosserman, billing clerk at Heartland Neurology in Lafayette, Ind.

Count nerves for NCS: You select from codes 95907 (Nerve conduction studies; 1-2 studies) – 95913 (Nerve conduction studies; 13 or more studies) depending upon the total number of separate nerves that are tested.

Tip: If diagnostic test results are normal or inconclusive for CTS, return to your plan of reporting the patient’s signs and symptoms. The physician’s documentation should explain signs and symptoms enough to establish medical necessity for any diagnostic tests and to support any additional E/M service your neurologist provides.

3. Submit Single Code Once Diagnosis Is Established

When your neurologist has established the diagnosis of CTS, focus on code 354.0. In this case, you do not report the codes for the signs or symptoms, such as numbness, tingling or finger pain. According to ICD-9, “Signs and symptoms that are integral to a disease process should not be assigned as additional codes.”

Reason: Your neurologist may be doing nerve conduction studies and/or electromyography to confirm the diagnosis of CTS. In this case, do not report the signs and symptoms as secondary diagnoses as these are integral to the primary definitive diagnosis.

4. Code for the Treatment Provided

Your neurologist may begin with noninvasive, conservative treatments in the early stages of CTS and include injections in later stages of the disease.

“Each insurance carrier, including many workers’ compensation regulations, has its own set of guidelines pertaining to treatment of CTS,” Hall says. “Contact your payer for specifics before moving to the next treatment step.”

Initial treatment may include pain-relieving medications and a wrist brace or splint. “Your provider may dispense a wrist splint for the home use of the patient,” says Hammer. “You report HCPCS splint code L3908 (Wrist hand orthosis, wrist extension control cock-up, non-molded, prefabricated, includes fitting and adjustment). This includes the fitting and adjustment services, so you may not additionally charge for these services. You typically would not report 29125 (Application of short arm splint [forearm to hand]; static) for the splint as this code is reported for the application of a posterior splint for fracture immobilization.”

When pain-killers, splints, and physical therapy have failed or cannot be used for one or more reasons, your neurologist may administer injections into the carpal tunnel to perform a nerve block and relieve the symptoms. If so, submit 20526 (Injection, therapeutic [e.g., local anesthetic, corticosteroid]; carpal tunnel). Depending upon what option your payer prefers, you report either modifier 50 (Bilateral procedure) or modifiers LT (Left side) and RT (Right side) when your neurologist injects both carpal tunnels.

If the symptoms still persist, your neurologist may refer the patient for surgical treatment to relieve the pressure on the median nerve.

Note: Ensure all treatments step are documented in the treatment plan, or payers may reject your claim based on lack of medical necessity.