Revenue Cycle Insider

Pinpoint the right diagnosis and procedure codes for CRPS every time.

When patients present with chronic pain in their legs, feet, arms, and hands, your provider may suspect complex regional pain syndrome (CRPS). But confirming this diagnosis and knowing how to report it can mean the difference between getting paid for your service and facing denials.

Check out a few key tips that will help you curb denials when treating CRPS, formerly known as reflex sympathetic dystrophy (RSD).

Lean Into E/M Criteria for Diagnosis

When your provider is evaluating whether a patient has CRPS, they’re likely to start with an exam. During that visit, the provider will ask the patient about their history, noting whether they recently experienced any injuries. This is important to document, since CRPS often develops within a month or so after injuries such as cuts, burns, fractures, sprains, or falls. If you want to achieve your best chances of bolstering a CRPS diagnosis, noting any recent injuries in the documentation will be essential.

The provider must also document the body area(s) affected, and whether the pain has spread from the original injury site to other locations — another common hallmark of the condition.

These elements will be important not only in supporting an ultimate CRPS diagnosis, but also in choosing the evaluation and management (E/M) level for the visit. For instance, if a new patient provides a comprehensive background of their pain’s progression, the provider performs a thorough examination, and several treatment options are discussed, the overall time on the date of service could exceed 45 minutes and/or the medical decision making (MDM) could qualify as moderate.

Either of these would warrant reporting 99204 (Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded).

The MDM may also be bolstered by any additional testing the physician orders, such as blood testing, MRI scans, X-rays, or other tests. These may not confirm a CRPS diagnosis, but they are often used to rule out other conditions, such as arthritis or osteoporosis.

Classify the CRPS Type

If your physician definitively diagnoses a patient with CRPS, you’ll need to know which type, because the ICD-10-CM code book provides different code sets for the two types:

• CRPS I: When a patient doesn’t have a confirmed nerve injury
• CRPS II: When the physician can trace the patient’s pain to an identifiable nerve injury

The biggest difference between them is that CRPS I does not include damage to the nerves, whereas CRPS II involves nerve injury. CRPS I is the most common type, representing about 90 percent of all CRPS cases.

To report CRPS I, you’ll submit a code from the G90.5- (Complex regional pain syndrome I (CRPS I)) range. You’ll choose the 5^th character based on the affected area, such as G90.51- (Complex regional pain syndrome I of upper limb) or G90.52- (Complex regional pain syndrome I of lower limb).

You can get even more granular if you know the side of the body affected, such as G90.512 (Complex regional pain syndrome I of left upper limb).

If you’re reporting CRPS II, take note of the Excludes1 note under the G90.5- section, which indicates that you cannot report CRPS II with any of the CRPS I codes. Instead, the ICD-10-CM Tabular List directs you to G57.7- (Causalgia of lower limb) for CRPS II of the lower limb and G56.4- (Causalgia of upper limb) for CRPS II of the upper limb. “Causalgia” is another name for CRPS II.

Navigate to the Right Treatment Codes

The physician may initially start treating the patient with pain management prescriptions — for example, anesthetic creams, antidepressants, nonsteroidal anti-inflammatory drugs (NSAIDs), anticonvulsants, corticosteroids, opioids — or they may decide on one of the following interventions:

• Sympathetic nerve block: 64510 (Injection, anesthetic agent; stellate ganglion (cervical sympathetic)) through 64520 (… lumbar or thoracic (paravertebral sympathetic))
• Epidural steroid injection (ESI): 62320 (Injection(s), of diagnostic or therapeutic substance(s) … including needle or catheter placement, interlaminar epidural or subarachnoid, cervical or thoracic; without imaging guidance) through 62327 (Injection(s), including indwelling catheter placement, continuous infusion or intermittent bolus, of diagnostic or therapeutic substance(s) … with imaging guidance)
• Spinal cord stimulator: 63661 (Removal of spinal neurostimulator electrode percutaneous array(s), including fluoroscopy, when performed) through 63688 (Revision or removal of implanted spinal neurostimulator pulse generator or receiver)

Note: The physician might also opt for a treatment like physical therapy (PT) or biofeedback. In these cases, care is often delivered by another healthcare professional. Check your claims carefully to see what treatment modality you are coding for, and who provided it.

Every payer covers CRPS diagnoses differently, so always consult your insurer’s policy or any local coverage determinations (LCDs) for Medicare patients to examine coverage guidelines before scheduling a patient for CRPS therapies.

For example, Aetna’s CRPS policy (0447) considers certain CRPS treatments (such as spinal cord simulators) medically necessary only if all of these criteria are met:

• The patient has been in pain for more than three months, despite conservative therapies (medication, physical modalities, exercises, etc.).
• The patient failed a trial of physical therapy.
• The patient failed a trial of nerve blocks with local anesthetics and steroids.

Some Medicare Part B payers also require practices to document which therapies were tried before the doctor decided to use spinal cord stimulators.

Putting It All Together

Check out this example of a patient who presents to the provider and is ultimately treated for CRPS.

A 37-year-old established patient presents with right arm pain from the elbow to the wrist. The pain is severe with a 7/10 pain level. The patient describes the pain as burning, continuous, and similar to electrical shock. Past medical history includes traumatic fractures to the right elbow and wrist with no nerve involvement three years ago. The provider spends 30 minutes with the patient.

The provider diagnoses the patient with right upper arm CRPS I due to traumatic elbow and wrist fractures without nerve damage, and performs a right cervical sympathetic nerve block to provide pain relief.

CPT^® codes: 64510 (Injection, anesthetic agent; stellate ganglion (cervical sympathetic) with modifier RT (Right side) appended and 99214 (Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded) with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service) appended

ICD-10-CM code: G90.511 (Complex regional pain syndrome I of right upper limb).

Torrey Kim, Contributing Writer, Raleigh, North Carolina